SAMSONPLAB ACADEMY

Bow Business Centre

Bow Road 153-159

E3 2SE, London

Telephone: +44(0)2089800039

Mobile:+447940433068

Email: info@samsonplab.co.uk

Contents:

1. Diabetes Mellitus

Acute Complications

a. Hypoglycaemia
b. Diabetic Ketoacidosis , (? e, n '0\ ("\ Y'
\-\S) \I pfr g\-1 cer(\·l C
)
c. Hyperglycaemic hyper-osmolar non ketotic coma (�

Chronic Complications
:::..1 1-\e

a. Microvascular
b. Macrovas.cular

2. Hyperthyroidism

a. Subclinical Hyperthyroidism

3. Hypothyroidism
 a. Secondary Hypothyroidism
b. Tertiary Hypothyroidism
c. Sub Clinical Hypothyroidism

4. Parathyroidism

a. Hyperparathyroidism
b. Hypoparathyroidism

5.Adrenal Glands

a. Cushing Syndrome
b. Addison's Disease
c. Conn's Disease
d. Pheochromocytoma

6. Acromegaly

7. Syndrome of In Appropriate Anti Diuretic Hormone

8. Hyperprolactinemia

9. Diabetes lnsipidus

1. DIABETES MELLITUS - This is high serum blood sugar

DM results from lack or reduced effectiveness of endogenous insulin.

It is imperative that a diabetic person having hypertension should have it well controlled.

TYPE 1 DIABETES

• Usually juvenile onset

• Common in young patients
• It is due to absolute deficiency of insulin
• An autoimmune condition in which there is destruction of the B cells of the pancreas
• Symptoms: Polyuria, Polydypsia, Weight loss, Diabetic Ketoacidosis
• First presentation can be Diabetic Ketoacidosis
• There could be history of other autoimmune conditions like Addison's disease, Thyroid
disease and Pernicious Anaemia
• Antibodies e.g. anti-glutamic acid decarboxylase (GAD) antibodies and islet cell
antibodies

TYPE 2 DIABETES

• Usually occurs in the adults mostly in Asian men and above the age of 40 years, most
are obese
 • Is due to insulin resistance and relative insulin deficiency
• Often it is asymptomatic and may first present with complications like diabetic
retinopathy, nephropathy and neuropathy
• RISK FACTORS: Pregnancy, obesity, polycystic ovarian syndrome (PCOS), renal
failure, lack of exercise

DIAGNOSIS: To make the diagnosis of diabetes, you need to consider the

following:

1 . If the patient is asymptomatic do the blood tests twice, either:

• Fasting glucose >7.0 OR i{ �"a\
:. y M v' 0 'IV' ')
• Random blood glucose> 11.0 confirms the diagnosis } Aw\c.<2.

Fasting glucose <6.1 is normal

Fasting glucose 6.1-7 is Impaired fasting glucose
Fasting glucose� 7.1 is Diabetes Mellitus

2. If the patient is symptomatic, perform one of the following tests once!

• Fasting glucose � 7.0 or
• Random blood glucose� 11.1

Do the Oral Glucose Tolerance Test (OGGT) if there is impaired fasting glucose. This is done
with 75mg of sugar and blood glucose is measured after 2 hrs.
• Glucose <7.7 is normal
• Glucose > 7.8-11 is Impaired oral glucose tolerance
• Glucose� 11.1 confirms Diabetes Mellitus
NB.
• Only venous blood glucose is used for making the diagnosis.
• Capillary blood glucose is only used for monitoring.
• For monitoring blood glucose control you monitor glycosylated haemoglobin
(Hba1c). Normal levels should be less than or equal to 6.1.

Prediabetes and impaired glucose regulation

Prediabetes is a term which is increasingly used where there is impaired glucose levels which are
above the normal range but not high enough for a diagnosis of diabetes mellitus.
The term includes patients who have been labelled as having either impaired fasting glucose (IFG)
or impaired glucose tolerance (IGT).

Terminology
• Diabetes UK currently recommend using the term prediabetes when talking to
patients and impaired glucose regulation when talking to other healthcare professionals
• patients identified at high risk should have a blood sample taken
• a fasting plasma glucose of 6.1-6.9 mmol/1 or an HbA 1 c level of 42-47 mmol/mol
(6.0-6.4%) indicates high risk

Treatment:
Impaired Glucose Tolerance Test
This is treated with diet and exercise.

T�pe 1 Diabetes Mellitus

In type 1 diabetes Insulin is always used but in different regimes e.g.

1 Twice a day if patient has a regular life style

2 Four times a day plus long acting at bedtime if a patient has variable activity e.g.
exercising.
3 Once a day in the morning long-acting when switching from oral hypoglycaemic
to Insulin

Type 2 Diabetes Mellitus

Stage 1 (Newly diagnosed):

• Diet and exercise
Stac9e 2 (Not controlled by diet and exercise alone):
• Diet and exercise +
• Oral hypoglycaemic
Stage 3 (Not controlled by above treatment):
• Diet and exercise +
• Oral hypoglycaemic +
• Insulin

Oral hypoglycaemic medication

1 Bigu_anicLes. e.g. Metformin
• Especially good for patients who are obe��- It is always the first choice. Increases insulin
sensitivity
• Weight loss
• Causes lactic acidosis
• Does not cause hypoglycaemia
• If glucose is not controlled add $yjfQD.�urea.
SE: rnausea) ���9 1acfic-acidosis
·----·.,.�---- - ---�

1 Sulfonylureas e.g. QILb�119�mi.de or Gliclazige

•
-
They increase insulin secretion via stimulation of insulin pancreatic beta cells
SE:�.----
ypogl¥caemiID
..,_

1 Thiazolidines e.g. Glitazones- Poiglitazone and Rosiglitazone

• They are used if patient not tolerant to either metformin or Sulfonylurea.
• They cause weight gain
• Causes hypoglycaemia

COMPLICATIONS OF DIABETES MELLITUS

A Acute complications

a Hypoglycaemia
b Diabetic ketoacidosis (OKA)
C Hyperglycaemic Hyper-osmolar non ketotic coma ( ,N�)
�1--\\-\S;
 A Chronic complications

a Microvascular = diabetic retinopathy, diabetic nephropathy, diabetic neuropathy,

autonomic neuropathy and somatic neuropathy.
b Macrovascular = Stroke, IHD, Intermittent claudication.
(Peripheral vascular disease) as a result of atherosclerosis

ACUTE COMPLICATIONS

1. Hypoglycaemia is glucose l��s thcm\3 mrrioi7t1

Symptoms:

�ijJ§)�Y{(3�1[og)tremor, jittering, aggressive, '---_,.�-- seizure, coma.

Loss of consciousness and sweating = hypoglycaemia until proven otherwise.

Treatment
1 If the patient is conscious give an oral sugary drink.
2 If the patient is unconscious then treat as follows:
• 1" choice is 10% glucose/dextrose
• 2.. choice 50% glucose/dextrose
• 3.. choice is Glucagon; disadvantage is that it does not work if there is alcohol in
the blood or in patients with anorexia nervos�. This is because glucagon acts by
converting glycogen into glucose. Glycogen 'is the storage form of glucose in the
liver.

CAUSES OF HYPOGLYCAEMIA

1 Insulin overdose especially in type 1 Diabetes

2 Glibenclamide and gliclazide in type 2 Diabetes
3 lnsulinoma = it is a benign tumour of the pancreas which produces insulin and it causes
hypoglycaemia. Usually every time a patient mis.s..es meal he loses consciousness or he
wi1, 1 have 1 • It occurs as part of MEN-1.
,�,
Investigation: C-;peptides and Insulin level in the blood.

2. Diabetic Ketoacidosis (usually it has gradual onset)

• Occurs or;ily iil type 1 Diabetes
• The criteria is pH< 7.3, HC03 <15, ketones in urine or capillary
• ABGs will show metabolic acidosis
• Precipitating factors: infection, surgery, Ml, Sepsis, UTI, Gastroenteritis and
Pneumonia

Symptoms/Clinical features:

Young patient, weight loss, polydipsia, dehydration, lethargy, anorexia, vomiting, abdominal
pain, coma, usually there is progressive drowsiness.

•
 1 MEDICATIONS: Amiodarone, thyro ine & lithium
1
C OlU'.;(l..:,
.- V fl?( I f c. '" .;<Y\
For amiodarone, the patient will be on treatment for arrhythmia (SVT, Atrial fibrillation
and atrial flutter)

For thyroxine, it is usually patients with hypothyroidism and on replacement therapy

with levothyroxine
• For Lithium these are usually patients being treated for bipolar mood disorder or mania.
� coin C'One \,,1 po o<\d yp0t �,1c)1d1�..:,i\\
Lithium can cause lSoth hypothyroidism and hyperthyroidism.

1 ECTOPIC TISSUE- this is thyroxine produced by anywhere else other than the thyroid
gland.

INVESTIGATIONS:

1 T3, T4, TSH (TSH is l�w and thyrnxi� is high)

_ c �.11. c) l
2 TSH Receptor ant1bod1es
3 If there is a mass in the neck then USS: if the mass is solid then do FNAC and if the
mass is cyst then do surgical removal/aspiration.
4 Isotope sGan =to decide if it is a hot nodule or cold nodule.

Hot nodule - usually indicates a benign adenoma. It accumulates iodine as it manufactures

thyroxine.

Cold nodule is usually cancer. It does not take up the contrast (iodine)

SUBCLINICAL HYPERTHYROIDISM

This is hyperparathyroidism with low TSH or symptoms but normal T3 & T4.

Treatment is observation

Medical treatment is needed only if TSH <0.1 or symptoms of AF, weight loss
Treat with carbimazole if treatment required

Sick euthyroid syndrome

In sick euthyroid syndrome (now referred to as non-thyroidal iJlness) it is often said that everything (TSH,
thyroxine and T3) is low. ( e v (.' r ·-; ·\ 1,', W· 1) l i-ii.,J)

In the majority of cases however the TSH level is within the normal range (inappropriately normal given
the low thyroxine and T3).

Changes are reversible upon recovery from the systemic illness.

Thyroid e-i-;e disease

 B Pre-Proliferative - Micro-aneurysms, dot and blot haemorrhages, hard exudates and
soft exudates (cotton wool spots)
C Proliferative - Micro-aneurysms, dot and blot haemorrhages, soft and hard exudates,
new vessel formation (neovascularization)
New vessel formation leads to bleeding which may cause retinal detachment which
comes as a sudden loss of vision and the patient complains as a cu a1nc oni1n down.
Cataract formation is earlier in a patient with diabetes.

Diabetic Maculopathy - This is when changes develop in the macula

Vitreous haemorrhage - This is when there is bleeding in the vitreous. The patient usually
rcomplairis of floater�

Diabetic Nephropathy

t\ll_icroalb.tJmin!-![ia- lo�i::gf >3{)0rog/g,ay of protein.

It is a big risk factor dfflf-1D and stroke therefore it needs treatment.
In people who are diabetic, the target BP is s 130/80 and if there is fDL9Eq-:�lbu11_1inurip
then target BP s125/75.

Microalbuminuria leads to diabetic nephropathy and eventually renal failure if not treated. In
renal failure insulin sensitivity increases and insulin metabolism decreases therefore insulin
needs to be reduced to avoid hypoglycaemic attacks.

Diabetic Neuropathy

1 Peripheral neuropathy (somatic neuropathy) is usually symmetrical in a form of gloves

and socks, usually from distal to proximal loss of sensation.
2 Mono neuropathy e.g. 3-, 4-and 6. nerve palsy.
3 Autonomic neuropathy will cause vasovagal syncope, diarrhoea, postural hypotension or
urinary retention.
4 Amyotrophy - progressive wasting and weakness of muscles especially the quadriceps
muscles. ( pic·,y)fV\-::,\

Metabolic syndro e
The pathophysiological factor is insulin resistance.

For a diagnosis of metabolic syndrome �t_ l��?t _� _of the following should be identified:

elevated waist circumference: men> 102 cm, women > 88 cm

elevatedftrlgl¥cerides.� 1_.7.mmol/L - ·-·�-· · ·
reduced HDL: < 1.03 mmol/L in males and < 1.29 mmol/L in females
�ised blood pressure: > 130/85 mmHg, or acffve
treatment of hypertension

raised fasting plasma glucose>

.. --------·-- ------�- ---�-
5_.6 mmol/L, or previously diagnosed type 2 diabetes
,.....,, ... . '

2. PITUITARY GLAND
Anterior Pituitary produces Growth hormone (GH), Gonadotropins: Follicle stimulation
hormone (FSH) & Leutenizing hormone (LH}, Prolactin (PRL}, Thyroid stimulating hormone
(TSH}, Adrenocorticotrophic hormone (ACTH)

Posterior Pituitary stores Oxytocin and ADH (Anti-diuretic hormone). These 2 hormones are
produced in the hypo halamus.
• Oxytocin acts on the uterus and causes contraction.
• ADH acts on the kidneys and cause urine retention.

NB: The ANTERIOR PITUITARY PRODUCES hormones and the POSTERIOR PITUITARY
STORES hormones.

Hypopituitarism
Hormones are affected in this order: GH, FSH & LH, PRL, TSH, ACTH

Causes are at 3 levels:

1 Hypothalamus: Kallman's syndrome (isolated FSH LH deficiency with anosmia

and colour blindness), tumour, inflammation, infection

1 Pituitary iia.lk: Trauma, surgery, compression by a mass lesion (eg. due to a

craniopharyngioma), carotid artery aneurysm

1 Pituitary: Tumour, irradiation, inflammation, autoimmunity, ischaemia (eg.

Sheehan's syndrome due to post partum haemorrhage)

Clinical features: depends on the hormone that is deficient and the underlying cause.

Investigations: Check for the specific hormones and look for the underlying cause eg.
MRI for pituitary tumour

Treatment: Hormone replaeement and treatment of the underlying cause.

3. HYPERTHYROIDISM - This is low TSH

Q-'<'
Hypothalamus �
!
Thyroid Releasing Hormone (TRH)
! � 0i''l'\€1t \C) �
Pituitary
.$�o,e
Gr\
F;::,\4
due
p'fo
\... \-,\
,5r\
AC(r-\
�PfL
 t
Thyroid Stimulating Hormone (TSH)
t
Thyroid gland releases: T3 and T4

SYMPTOMS OF HYPERTHYROIDISM

1 Weight loss, tachycardia, diarrhoea, oligomenorrhoea, irritability, heat intolerance,

tremors, sweating and weight loss despite increased appetite, atrial fibrillation/sinus
tachycardia
2 Typical signs of Graves disease are exophthalmus, ptosis, diplopia, lid retraction, lid lag

CAUSES:

1 GRAVES DISEASE

It is an autoimmune disease. Antibodies resembling TSH are formed and act on the thyroid and
stimulate production of T3 & T4. It is associated with other autoimmune disease like type 1
diabetes, Addison's disease, Vitiligo.

There is diffuse enlargement of the thyroid gland. There is bruit and eye signs e.g. diplopia,
exophthalmus.

Treatment: ,9irbimazofel In pregnancy use Lf)rQQYJtbjo.JJJacjJ.lGive beta blockers, for

symptom control, if no contraindications like asthma.

1 TOXIC ADENOMA -1,/

\

/'
It is a benign "tumour of the thyroid gland and it produces thyroxin. It is a{solitary adenoma;1
which means there will be a lump in the thyroid which(nioves on swall?�ingJ

Treatment isfra-�io-iodine

3. TOXIC MULTINODULAR GOITER

'•
There are multiple nodules, which produce thyroxin. (, i,. ·, \

Treatment is t-Carbimazole' and '..radiotherapy\

,.... -.

4. S_lJ_�-��YTE THYR_QIDITIS - This is also known as(ITe:qi.iervaTnTs thYr6iditi�)

The cause is viral infection i.e. Upper Respiratory Tract Infection. The t_by_r:Qid is usually
-- -
(p�Jl!!L�_nc:I efilarged1
Treatment is analgesia or observation
 1 MEDICATIONS: Amiodarone, thyroxine & lithium
1.. r CIU'
.;P.) 'I I)<' ( � fl dd 1 � .f1 \
For amiodarone, the patient will be on treatment for arrhythmia (SVT, Atrial fibrillation
and atrial flutter)

For thyroxine, it is usually patients with hypothyroidism and on replacement therapy

with levothyroxine
• For Lithium these are usually patients being treated for bipolar mood disorder or mania.
Lt'- co1ri ,, J)'(l k 1 po or\cl yp0r \,,c11cl1'.'.)\\\
Lithium can cause 150th hypothyroidism and hypertmyroidism.

1 ECTOPIC TISSUE- this is thyroxine produced by anywhere else other than the thyroid
gland.

INVESTIGATIONS:
1 T3, T4, TSH (TSH is low and thyroxin is high)
2 TSH Receptor antibodies i. '�., �c1 'i
3 If there is a mass in the neck then USS: if the mass is solid then do FNAC and if the
mass is cyst then do surgical removal/aspiration.
4 Isotope scan=to decide if it is a hot nodule or cold nodule.

Hot nodule - usually indicates a benign adenoma. It accumulates iodine as it manufactures

thyroxine.

Cold nodule is usually cancer. It does not take up the contrast (iodine)

SUBCLINICAL HYPERTHYROIDISM
This is hyperparathyroidism with low TSH or symptoms but normal T3 & T4.

Treatment is observation

Medical treatment is needed only if TSH <0.1 or symptoms of AF, weight loss
Treat with carbimazole if treatment required

Sick euthyroid syndrome

In sick euthyroid syndrome (now referred to as non-thyroidal i,llness) it is often said that everything (TSH,
thyroxine and T3) is low. > ,. , )
C (' v (' r ·-,; · 1 ) ,-,u; i

In the majority of cases however the TSH level is within the normal range (inappropriately normal given
the low thyroxine and T3).

Changes are reversible upon recovery from the systemic illness.

Thyroid eye disease

Thyroid eye disease affects between 25-50% of patients with Graves' disease.

Prevention
[smo!sVi�is the most important modifiable risk factor for the development of thyroid eye
disease
radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye
disease.

In a recent study of patients with Graves' disease around 15% developed, or had worsening of, eye
disease. Prednisolone may help reduce the risk

Features
the patient may be eu-, hypo- or hyperthyroid at the time of presentation
exophthalmos
conjunctiva! oedema
optic disc swelling
ophthalmoplegia
inability to close the eye lids may lead to sore, dry eyes. If severe and untreated patients
can be at risk of exposure keratopathy

Management
topical lubricants may be needed to help prevent corneal inflammation caused by
exposure
sterbids
radiotherapy
surgery

4. HYPOTHYROIDISM - This is high TSH

CAUSES:
1 Hashimoto's Disease
Thyroid is diffusely enlarged)
It's an autoimmune disease and is associated with pernicious anaemia, Diabetes mellitus type
1, Addison disease. Antibodies: anti-peroxidase, Anti-thyroglobulin, anti-microsomal
antibodies

1 Primary Atrophic Hypothyroidism

a Diffuse infiltrate, which leads to atrophy of the thyroid. It is an autoimmune
disease. There is no goitre. The thyroid gland is small.

1 Iodine Deficiency
Common in Africa where water is not iodized.

1 Thyroidectomy

1 Radio-iodine Therapy
SYMPTOMS OF HYPERPARATHYROIDISM are mainly due to hypercalcaemia. These are
weakness, tiredness, depression, polyuria, polydipsia,tcq_rifi,isJ0ril \tbJrsLand abdominal pain and
constipation.

Parathyroid adenoma is usually associated with MEN1 (Multiple Endocrine Neoplasia).

MEN syndrome consists of

MEN 1

Pancreas tumour =gastrinoma

Parathyroid adenoma
Pituitary adenoma

MEN 2a

Thyroid tumour
Adrenal adenoma
Parathyroid adenoma

MEN 2b

Thyroid
Adrenal
Parathyroid
Mucosa! neuromas

Zollinger-Ellison disease is multiple ulcers in the stomach, duodenum and small intestine,
which are poorly responsive to PPI and caused by Gastrinomas occurring as MEN 1.
Gastrinoma is a tumour of the pancreas, releasing gastrin. This causes increased HCI, leading
to peptic ulceration.

INVESTIGATIONS FOR HYPERPARATHYROIDISM

1 Serum Calcium
2 Parathyroid level
3 Bone scan for osteoporosis
4 USS of the parathyroid and thyroid

Treatment: SURGERY

1 SECONDARY HYPERPARATHYROIDISM

Causes:

1 Deficiency of vitamin D
2 Chronic renal failure- Active vitamin D is formed in the kidney.
3 Malabsorption

Treatment: Active vitamin D and calcium.

HYPOPARATHYROIDISM

CAUSES:

1 Thyroidectomy: Usually during thyroidectomy the parathyroid glands are removed as

well.
2 Symptoms are those of hypocalcaemia i.e. tetany and oeri-oral parasthesia

Chovestek sign- when tapping on the angle of the jaw there is twitching of the muscles of the
face.
Trousseau's sign- when you tie the BP cuff on the arm there is flexion of the forearm and
fingers. This sign is also called carpal pedal sign.

Treatment:

1 Calcium Gluconate intravenously if severe

2 Calcium supplements if mild (Oral Ca tablets)

6.ADRENAL GLANDS

HYPOTHALAMUS
t
Corticotropin Releasing Hormone (CRH)
t
PITUITARY

ACTH
t
ADRENAL GLAND

{Glucocorticoid (CORTISOL)
Mineralocorticoid (ALDOSTERONE)
Androgens}

Catecholamine's (adrenaline, noradrenaline) - From the Medulla

DYSFUNCTION GF A DRENAL GLANDS

A HYPO FUNCTION OF THE A DRENAL GLANDS

Addison's Disease - low production of cortisol mainly due to autoimmune disease and infection
e.g. tuberculosis

A HYPER FUNCTION OF THE A DRENAL GLANDS

1 Pheochromocytoma- tumour of the adrenal glands from the medulla, produces

catacholamines.
 2 Conn�s �isease- adenoma of the adrenal cortex producin� aldosterone
3 Cushing s syndrome- see below ( ·1.l::.� Of'I<?� C)\cir"d \ c-10r{l.r\C1I
4 Virilization- increased production of he androgens
I
C' lf':.}(, I(\ CJ d,��:>r•�, C' • S"y'.-\el'Y\i C
CUSHING'S SYNDROME (cl '('.)\�"'d.J)
This is excess of cortisol from any cause

CAUSES:

1 Cushing disease
This is high cortisol due to pituitary adenoma
This is the commonest cause
Cushing disease is when the tumour is located in the pituitary and produces high A'CTH which
stimulates the adrenal gland to produce high cortisol

1 Adenoma of the hypothalamus

This leads to high production of corticotrophin releasing hormone - high production of ACTH
leads to high production of cortisol in the adrenal glands.

1 ACTH produced by lung cancer usually caused by s mall cell lung cancer

1 Iatrogenic i.e. patient on treatment for Addison's disease.

1 Adrenal adenoma - this tumour of the adrenal glanes.

Symptoms of Cushing Syndrome:

1 Weight gain
2 Mood changes
3 �ntra o es1t
4 Acne (spots on the face)
5 (8mennrrtiea)orJrr,eg!JJar. menstrual,
6 /Hi�sutfsm)(facial hair)
7 'Moon face
8 Buffalo hump
9 Impaired glucose tolerance test
10 Hypertension
11 Abdominal striae
12 Acanthosis Nigricans

DIAGNOSIS

1st LINE INVESTIGATIONS (SCREENING TEST)

(24 hour) Overnight Dexamethasone suppression test or 24 hour urinary free cortisol.

2nd LINE INVESTIGATION (CONFIRMATION TEST)

If any of 1. line test is positive go for 2.. line.
Which are 48 hour Dexamethasone suppression test OR Midnight cortisol/diurnal cortisol

3rd LINE INVESTIGATION (LOCALIZATION TEST): To find where is the lesion.

Plasma ACTH: It is usually not detectable in blood.

A If, it is increased or detectable- (May be Ectopic or may be Pituitary cause). Perform

high dose Dexamethasone suppression test.

1 If cortisol is suppressed, the diagnosis is Cushing disease. Do MRI of the pituitary

because the most likely locations the pituitary gland.
2 If cortisol is not suppressed, the diagnosis is likely to be due to an ectopic tumour. Do CT
scan to locate the carcinoid tumour.

B. Decreased or undetectable - do CT Scan of adrenal glands. If no mass is visible on the CT

scan then perform Adrenal Vein Sampling.

TREATMENT

- Surgery
- If iatrogenic - Remove the cause.

ADDISON'S DISEASE - Low Cortisol

Causes

1 TB (Most common in developing world)

2 Autoimmune (Commonest Cause)
3 Metastasis
4 Steroid
5 HIV
6 Waterhouse Friderichsen Syndrome (Haemorrhage in the adrenal gland in a patient with
meningococcemia)

Symptoms

1 Xfati ue
2 Abdominal Pain
3 Nausea
4 Vomit'n
5 �H�e �[Qm (hyperkalemic hypotensive)
6 Weight loss
7 Anorexia
8 Diarrhoea
9 Constipation
10 Hyperpigmentation
11 Vitiligo
INVESTIGATIONS

1- In a patient with suspected Addison's disease the definite investigation is a ACTH stimulation test
(short Synacthen test). Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug
IM.

2- Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated.

3- If a ACTH stimulation test is not readily available (e.g. in primary care) then sending a 9 am serum
cortisol can be useful:
> 500 nmol/I makes Addison's very unlikely
< 100 nmol/I is definitely abnormal
100-500 nmol/I should prompt a ACTH stimulation test to be performed

Associated electrolyte abnormalities are seen in around one-third of undiagnosed patients:

hyperkalaemia
hyponatraemia
hypoglycaemia

metabolic acidosis

RISK FACTORS

1 Surgery
2 Infection
3 Sepsis
4 Trauma

TREATMENT
• Replace steroids
• Hydrocortisone
• If Postural Hypotension- Fludrocortisone

CONGENITAL ADRENAL HYPERPLASIA

Congenital autosomal recessive disease characterised by cortisol deficiency, with or without

aldosterone deficiency and androgen excess.
It has 2 types: classic and non-classic.

CLASSIC: severe form. It's either salt losing or non-salt losing

Symptoms:
FEMALES: Classically presents with ambiguous genitalia with enlarged clitoris and one
combined sinus instead of a separate urethra and vagina. May experience salt-losing
adrenal crisis.

MALES: classically present with no si9ns at birth.

Those with salt-losing form typically present at 7-14 days with vomiting, weight loss,
lethargy, dehydration, hyponatraemia and hyperkalaemia.
• Those with non-salt-losing form present with virilisation at age 2-3

NON-CLASSIC: mild or late-onset form, they present with hyperandrogenism in later childhood
and early pubarche, infertility, hirsutism, amenorrhoea, polycystic ovaries.

Investigations:

Renal function, electrolytes, blood glucose, serum 17-hydroxyprogesterone, corticotropin

stimulation test, pelvic ultrasound.

Treatment:

Classic: Standard hormone replacement, these include glucocorticoids,

mineralocorticoids

Non-classic: Treatment only symptomatic.

CONN'S DISEASE
This is excess aldosterone, which causes Na+ retention

CAUSES:

1 Adrenal adenoma
2 Bilateral hyperplasia

SYMPTOMS:

1 k+ decrease.?)
2 ,Na-:t:. lncreased,or normal
3 eaknessJ
...... :::\
4 tramps (muscles, --- ·
5 Pofyuria
6 Polydipsia
7 Parasthesias
8 Hypertension (Hypertensive Hypokalaemic)

INVESTIGATIONS

1 Aldosterone/ Renin ratio altered or altered Serum Aldosterone

2 CT adrenal

TREATMENT

1 Hyperplasia- Medicine (Spironolactone/Amiloride)

 2 Adenoma- Surgery (Spironolactone given 4 weeks pre-op

PHEOCHROMOCYTOMA

This is due to increased effect of catecholamines, usually due to adrenal tumour.

fule__of_;tOJ
10% Malignant
10% Bilateral
10% Extra-adrenal
10% Children
10% Familial
Increased Catecholamines, associated with MEN-2.

SYMPTOMS:

1 Episodic yperten�_i��and /heagac;t,eSJ

2 Anxiety
3 /S�eating)_
4 \PajJ;>i.@tiqn �
5 Flushing
6 Nausea
7 Vomiting
8 Abdominal pain
Episodes or intermittent symptoms

INVESTIGATIONS:
• 24 hours urinary collection for Catecholamines/Metanephrines

TREATMENT:

A CRISIS:

Phentolamine
ii Labetalol (Selective 8-Blocker)

A STABLE PATIENT:

Alpha- blocker (Phenoxybenzamine) followed by

ii Beta- blocker (Propranolol)

Surgery is done after 2 weeks of BP control.

Treatment. Surgical removal of adenoma

7. ACROMEGALY

1 Increased growth hormone (GH)

2 Pituitary tumour (tumour compressing on the optic chiasma - Bitemporal Hemianopia)
 Hypothalamus
L
Growth Hormone Releasing Hormone (GHRH)
L
Pituitary
L
Growth Hormone
L
Promotes muscle and bone growth

SYMPTOMS

1 Increase in ring & shoes size

2 Spade like hands
3 Widespread teeth
4 Hoarse voice
5 Carpel tunnel syndrome
6 Excessive sweating
7 Visual field defect --> Bi-temporal Hemianopia
8 Coarsening of facies
9 Prognathism
10 Macroglossia (enlarged tongue)

COMPLICATIONS

1 m aired Glucose Tolerance Test\

2 Increase BP
3 Cardiomegaly, Hypertrophy
4 Increase IHD

INVESTIGATIONS:

1 Definitive- OGTT (Oral glucose tolerance test)

2 MRI of the pituitary gland
3 Serum insulin like growth hormone

TREATMENT: Surgery.

8. SIADH -Syndrome of Inappropriate Anti Diuretic Hormone

This is due to overproduction of ADH which leads to reduced production of urine.

Symptoms:
• Water Retention leading to hyponatraemia and hypertension
• Confusion, nausea, and seizure.
� >KJc-:c\r'
t,) <.)
CD\
CAUSES:
1 Lung cancer-:S�aif cell lung _9�11q�t:
2 Pancreas Cancer
3 Prostate Cancer
4 As a complication of Meningitis and Head Injury

DIAGNOSIS:
Urine Osmolarity over than 500 mosmol/kg
Plasma Na+ <125 mmol/kg, plasma osmolality <260 mosmol/kg

TREATMENT:
1 Fluid restriction if complication of meningitis or head injury
2 Treat the cancer

9. HYPERPROLACTINAEMIA

Hypothalamus
!
Prolactin Inhibitory Factor (PIF) (DOPAMINE)
!
Pituitary
!
Prolactin
!
Lactation (Breast)

This is the commonest hormonal disturbance of the pituitary gland. Raised level of Prolactin
(PRL) leads to( ogonad1� tinfertilitY,1' and psteQporosj
-- 'l
y , \
.·.,,. t'', t..J�\
• Normal PRL level is <400 mU/L
\-\ l\'-'A ,· \,\ '•/

6�<;(i 1:/,,, .,,·,

If the PRL is mildy elevated (400-1000 mU/L) then repeat before referral consider look
for causes other than a prolactinoma.

Very high PRL >5000 mU/L usually means that a prolactinoma is present.

CAUSES OF RAISED PLASMA PROLACTIN:

1 Excess production from the pituitary gland by a Prolactinoma

2 Disinhibition, by compression of the pituitary stalk, reducing local dopamine levels.
3 Use of dopamine antagonist
4 Physiolo_gical: Pregnancy, breastfe.§ding
5 Drugs: e ac opr'ainide, a o erido an'--�rp"""
sy�chofics

SYMPTOMS:

1 Amenorrhea
2 Infertility
3 Galactorrhea (milk discharge from the nipples)
4 Reduced libido
 5 Weight gain
6 Dry vagina
7 Erectile dysfunction in men

INVESTIGATION
• Serum prolactin levels

TREATMENT
• Dopamine agonist e.g.fsromocriptin� .. {J;)
• Surgery for adenoma. -

10. DIABETES INSIPIDUS

This is passage of large volume, greater than 3 litres per day of dilute urine, due to impaired
water reabsorption by the kidney

There are two types

1 Neurogenic/Cranial Diabetes lnsipidus: Reduced ADH secretion from the Posterior

pituitary
2 Nephrogenic Diabetes Insipidus: Impaired response of the kidney to ADH

SYMPTOMS:

1 Polyuria
2 Polydipsia
3 Dehydration (In dehydration Na+ is high)
4 11:fypernalraerrifa) 00 ( �)("l·\r• (

CAUSES OF NEUROGENIC DI:

1 Idiopathic
2 Congenital
3 Tumor
4 Trauma
5 Hypophysectomy
6 Autoimmune hypophysitis
7 Infiltration - Sarcoidosis
8 Vascular
9 Infection

CAUSES OF NEPHROGENIC DI:

1 Inherited
2 Metabolic . . _ .
_....,._.... U � C
1
'''J{Old
3 Drugs e.g.\hthiurril ,# ·\

4 Chronic renal disease

5 Post-obstructive Uropathy

DIAGNOSIS:- The water deprivation test.

TREATMENT:
-For Cranial DI- Find the cause (MRI- head)
-For Nephrogenic- Treat the cause
-Desmopressin (ADH) for therapeutic trail

Corticosteroids
Corticosteroids are amongst the most commonly prescribed therapies in clinical practice. They are used
both systemically (oral or intravenous) or locally (skin creams, inhalers, eye drops, intra-articular).

They augment and in some cases replace the natural glucocorticoid and mineralocorticoid activity of
endogenous steroids.

Side-effects
The side-effects of corticosteroids are numerous and represent the single greatest limitation on their
usage. Side-effects are more common with systemic and prolonged therapy.

Glucocorticoid side-effects
endocrine: impaired glucose regulation, increased appetite/weight gain, hirsutism,
hyperlipidaemia
Treatment for Impaired glucose regulation: Insulin or oral hypoglycemics

Cushing's syndrome: moon face, buffalo hump, striae

musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral
head
Treatment for osteoporosis:�Bjsphosphonate�

immunosuppression: increased susceptibility to severe infection, reactivation of

tuberculosis
psychiatric: insomnia, mania, depression, psychosis
gastrointestinal: peptic ulceration, acute pancreatitis
Treatment for Peptic Ulceration: Protein Pump Inhibitors (PPI)

ophthalmic: glaucoma, cataracts

suppression of growth in children
intracranial hypertension

Mineralocorticoid side-effects
fluid retention
hypertension

To prevent adrenal insufficiency:

1- patients on long-term steroids should have their doses doubled du�ing intercurrent illness
 2- withdraw gradually if patients have: received more than 40mg prednisolone daily for more
than one week,
received more than 3 weeks treatment or
recently received repeated courses

Hypokalaemia and hypertension

For exams it is useful to be able to classify the causes of hypokalaemia in to those associated with
hypertension, and those which are not
\ •'" /"' \

Hypokalaemia with hypertension ·0\-- '! �'.') �� V' \

i._

Cushing's syndrome
i�j __ ,_,,

-� \->ix>
Conn's syndrome (primary hyperaldosteronismL._--
�i9_gle's syndrome ( Liddle syndrome is an inherited form ofJlY.P.�_rte@i.9n. This condition
is characterized by severe hypertension that begins unusually early in life, often in childhood,
although some affected individuals a e not diagnosed until �dulthood Hypokalaemia without
� h pert�nsion T�eatment is with either ;3miloride or triamterene)
· .•� • r. diuretics
� '
'(t' l--
• GI Joss (e.g. Diarrhoea, vomiting)
-,-r11 : 'o, • renal tubular acidosis (type 1 and 2) T� �
\--· i &'l �p • Bartter's syndrome

Bartter's syndrome
Bartter's syndrome is an inherited cause (usually autosomal recessive) of severe hypokalaemia due to
defective chloride absorption at the Na+ K+ 2CI- cotransp0rter (NKCC2) in the ascending loop of Henle. It
should be noted that it is associated with normotension (unlike other endocrine causes of hypokalaemia
such as Conn's, Cushing's and Liddle's syndrome which are associated with hypertension).

Features
usually presents in childhood, e.g. Failure to thrive
polyuria, polydipsia
hypokalaemia
normotension
weakness

Carcinoid tumot1rs
Carcinoid syndrome
usually occurs when metastases are present in the liver and release serotonin into the
systemic circulation
may also occur with lung carcinoid as mediators are not 'cleared' by the liver

Features
'flashing (often earliest symptom)
Id arrhoe_
.(brgn_�t19_sP9."��
 hypotension
right heart valvular stenosis (left heart can be affected in bronchial carcinoid)
other molecules such as ACTH and GHRH may also be secreted resulting in, for
example, Cushing's syndrome
pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour

Investigation
urinary 5-HIM
plasma chromogranin A y

Management
somatostatin analogues e.g.� reo, e
diarrhoea: cyproheptadine may e p
SAMSONPLAB ACADEMY LIMITED
Email: info@samsonplab.co.uk
Tel: 07940433068
Address: Bow house Business Centre
153--------159 Bow Road London
E3 2SE

B. Beta blockers
/@ Calcium channel loc e s

B. Corticosteroids
C. Surgical treatment
D. Carbamazepine
-/@ acetazolamide

1
 3. Patient present with hir�utism. He is on the following drugs
which one�'!V9LJldfuoJfl ha_y�J�g_�J:l--��e ca�_E?:_
A. Minoxidil ,
B. Cyclosporine a /
C. Steroids -, ,·
/(g; Sodium valproate0
E. Phenytoin /

4. A 1_1-year old woman presents with a ra idly_eru

the neck. She has recently developed \Strt m3 an��-­
palpation, the mass is(,bar 'and(tetheredjto th
most likely diagnosis?
A. Thyroid adenoma
B. Follicular carcinoma
./ :,' C)Anaplastic carcinoma

'. ashimoto's thyroiditis

t. Viral thyroiditis \po1,\,0\ eV\\orge f\J\{>1,.\ \

E. Low sodium

2
 6. AI� year old woman presents withH,�loleran�e to hea1) and
lfweatm of the\hand.s.) she has a �m_gq_t:h, �oft thyroid swe1ltng
with a bruit. What is the most likely diagnosis?
./@ Grave's disease
B. Drug induced
C. Viral thyroiditis
D. Thyroid cancer
E. Iodine deficiency

'fJ;ll
�
7. A �2-year old woman develops a smo_p__.th swellin'g in nec_k,
i
lsensif vrty to co ra ycardi.a'l and a1r oss -'Pieri blood count
shows a acrocytic anaemial What is the most :ikely cfiagnosis?
,/@ Hypothyroidism
B. Hyperthyroidism
C. Iodine deficiency
D. Grave's disease

8. A _5_5-year old _o ,a presents with iocreasing obesjty. On

examination, sh has c ntral_ o__besity with a ound mo n face
She is hyRertensi and has g�_yc;.9su�ic1. An ultrasound of her
abdomen ret eal� an �nlarged .. f1ghc �adren:a;r-glang. The left
adren�J g 1s riormal. What is the most likely diagnosis?
1

A. Ag,. i� i,sease d i �eo�e ( c.ery\ta\�

3'jfQ(O (Y\e
f
\\
11
.,/ 8 Cus i I g c jsear ' �� oc}ff'(\{"'A o\nr�)
{j�� ,(Q\o 1 u:,
-- __ ec-\E?d
naeochromocytoma o (e, o�(
0. Conn disease
E. brain tumour

9. A patient with _BML37 with a _fat nec;:__k complains of tiredness

and sleepiness during the day and also �nore� c),t night. What is
the choice of investigation to confirm the diagnosis?
3
 A. ABG
B. Chest X-ray
C.OGD
1(0 Sleep study ( �>0\1 _,c)�1\'\C>g10,)h'/ \)
E. Pulse oximetry

10. A 42-year old man is found at routine medical examina t A o

have a !?_�ood pressu_r,e ofQ70/1m mmHg. On questioni � he
admits to bouts of (tjiarrhoea sev�ra times a week. 14e ha·s been
complaining ofQn�er·mftt�n:rJiead_�chs� and Ral ita ions 6r some
months. What is the most likely diagnosis?
A. Cushing disease
B. Hyperthyroidism
.,,,. <f) Phaeochromacytoma
D. Conn disease
E. Acromegaly

11. A 60_�y_e_a.r old woman is o nd to have an ie..Yated. cakiuinJ

level on a routine lli0c . i al profile. Repeated measurements
confirm the findii:1 . is the most likely diagnosis?

�fldrome
.......ill..
D. '/1..c o�egaly
haeochromacytoma
�

12. A 40-year old man presents with thirst 1ROlyuria and marked
muscle weakness. His Qlood pressure is\1 �0!1 0)mmHg. His serum
sodium concent;.@!!__on is normal and his serum pQ. as.sn. 1_
concentration is \!.� His b.JQQCL.gluc_o.se is r,9rm.?.1l. What is the
most likely diagnosis?
A. Cushing Syndrome
4
 B. Phaeochromacytoma
C. Addison disease C lr\y pcY\€r"\'5'()(\ \ ( o rt)
/(5) Conn syndrome
E. Diabetes

13. A Z5_-year old '1-/oman presents with !12aroxys!:1J�I. nocturn . l

,.dyspnoea and on examination she is found to have a_ ·at
[fibrillation' What is the most likely diagnosis?
.//@ Hyperthyroidism
B. Cushing
C. Conns
D. Diabetes
E. Phaeochromacytoma

14. A 14-year old �uthyroid ( o m serum T4 concentration) girl

presents with soft diffusely e lar' d thyroid gland, which moves
freely on swallowing. Wha ·. t e most likely investigation?
AATSH
. T4 &T3
C. Isotope

E.T and T3

5
 16. A �uthyroict (normal serum T4 concentration) 25·year old
woman has a �olitary, solid thyr.oiq (noduleJ confirmed on
ultrasound scan. What is the most appropriate investigation?
A. USS
. ./B FNAC
C. CT scan
D. TSH
E. T4

B. FNAC
C. TSH
D.T3
E. T4

18. A 30.:-yeat old\�oman with a normal serum T4 concentration

has P.alg·ira ·ons/trem9r and weight�-- lQ�.s. What is the most
approprfat investigation?

·-1· ". \--\ ./-

_, .}

E. Isotope

19. An ei_ght·y�ar old boy is admitted to a surgical ward following

a road traffic accident. He is found to have g�ycosl:Jria. When he
 recovers from his injury, the g_�c::q�y[ia re�q_ly��- What 1s the
most appropriate next step?
J@ Fasting glucose
B. Random glucose
C.OGTT
D. No Investigation
E. Insulin

20. A five-y�ar old boy attends with his mother; she is con\ erned
that .b� may have gi-9:p_�tes. He is asymptomatic. W /at is A1e most
appropriate investigation?
/@ Fasting glucose
B. Random glucose
C.OGTT
D. Insulin
E. Urine Glucose

21. A five-year old �itl Rre ents with a histQry of(f[�_g��otfau ts)
when i�e misses meal he is concerned she may have diabetes.
What is the singl , 0sE appropriate investig�tjon?
A. Fasting gt os

22. A -11 years old_QQY with type 1 diabetes has �oo.r l9_o_g�te�rn
�ontrol. He is admitted YD.fQD_�ci9�s to the children's ward. He is
byperver1t.H�tjr,g and appears cte�ydrated. What is the most
appropriate investigation? · ·· ·

7
 A. Fasting Glucose
,... . ·,
\
�'
/@ABG \. \( \
\ � j .,I

C.U&E
D.FBC
E. NONE

23. A 2�-year old woman presents to the accident a d

emergency Department with a on� w��J< histq_ry of vomi i'fil b
gives a history of \jncreasing ·thirs and fcorfstipation 0.r �wo
months. Four years earlier she had a 1left mastectomy/ d ,oHlary
clearance for breast cancer. She is talking tamoxif, n a-� . enna.
What is the most appropriate investigation? t"- " .. ..., I ,·
, I\
· ., · t t·'t 1 • i O I..1
A. Plasma glucose concentration
8. Serum amylase concentration
,AC Serum calcium concentration c · 'i'Y'\ ,{ Pb wn e \
\ vv--Q"\ \'Y,;l) \0,jl� )
J

D. Serum sodium concentration

E. Serum urea concentrati , n

24. A 93-year old w . n is admitted[confuse- and((ethargic She

is known to hav h � tension but her blood pressure is well
controlled on a ttrazide diuretic. Her electrocardiogram (��G) is
""'normal.
---· �ype1 \"i::{"'1\(r-.11)1
�" rcU \:' c:i(er-iitn
cor,{U".:l\Ot)
J •,,
('(.", t,J�
\ow

25. W�ightf
. loss may .cure .the ... disorder, 1-rJlJ?rove the \d.aY\��� /
1 Jµnctfonff g""'\ and improve ,tftarital retatforishi Which of the
following is true about the above statement?

8
 A. Type 2 diabetes
B. Type 1 diabetes
/@Obstructive Sleep apnoea
D. Cushing disease
E. Hypothyroidism

26. Weight .loss may improve the �on.dition and even help to s�o
the_med.ic:;:_c1tions for this con9ition. Which of the following opti, s
is true about the above statement?
At.._,
A. Obstructive sleep apnoea �
B. Polycystic ovarian syndrome
C. Cushing syndrome
-./ Type 2 diabetes
E. Hypothyroidism

27. Stoppage of this will helP. loss and vitamin

deficiency. Which of the follo ·.og I
,,o'fl'i(\
A. Obstructive sleep apnoea

28. S, r.ge f.6r this condition in a fem�le will help in w�ig_ht_ lo�s
anGf..iim r ve the_ �ondHton?
�- us ing syndrome
- . :Alcohol Abuse
G. Polycystic �dney dise-as-e) O\JDrio r\ �yMro Me
D. Type 2 diabetes -,·�
E. Hypothyroidism

9
 29. A_�5-�year old woman presents with increasing obesity. On
examination she has central ob�sity with a(roun moon _face She
is _hypertensive and has glycosuria. An ultrasound scan of her
abdomen shows reveals an�nlarged right adrenalglan The left
adrenal gland is normal. What is-the single\ hormone most likely
to be responsible? l,.
( ''" ,f, .. (")
· ..·, ft l('\:··f
\ ,,.,
t( 1H· .,
-

A. calcitonin
j® Cortisol
C. Glucagon
D. Adrenaline
E. Insulin

A. Cortisol
B. Insulin
C. Aldosterone
.Ii D Adrenaline

31
· A G" ,ear ol woman presents with\thrrst ol una and marked
scle weakness .. His blood pressure is 150/ 110mmhg. His serum
s- - it:J concentration is 140 t'ancf pofass1um) is (2. 71.-½His blood iJ \ {
� l:JCOSe is ]Ammol/l. Which single hormone is likeli to be ...� ec, 1 '<\

mvolved? \'\O( (\I"\

..
., ,::�. .. c::--�
.J .. ...__)

A. Thyroxine
B. Calcitonin
C. Parathyroid hormone
/i D Aldosterone

10
 E. Vasopressin /\0\\.

32. A 40-year old man is found to have [elevated calClUIJl levels on

routine biochemical profile. Which single hormone is involved?
A. Calcitonin
,/j B Parathyroid hormone
C. Cortisol
D. Insulin
E. Glucagon

33. A 45-year old woman presents with weigh loss despite very
good appetite? On examination she is four,i�, �ave irregularly
.
i[r�g!,Jl�LP.�1$� e. Which hormone is involved1-, Y
,
A. Adrenaline
B. Cortisol
/i C Thyroxine \, �)
D. Insulin
E. Soma-statin

34. An 18-year ola emale who is a known diabetic type 1

presents wit de aration and increasing drowsiness -for the past
24 hours. Ofl e;. amination she is found to have deep fast and
�jg_bing 1-es itati9n of :4.QL!JIJD. What is the single most useful
inve g�10n?
/t Ph urea and electrolytes
Serum amylase
Random blood sugar
D. Glucose tolerance test
E. Fasting glucose

11
 ••\i ("\

35. A 29-year old �an__ pr.esents with\Jfolyurial and�pQlydj_psia She

is found to have [m_OC>[l_Jace and c�ntral_obesity and is .§Sil
bruised. Blood glucose is 25mmol/l. What the single most useful
investigation?
A. Random blood glucose
B. Fasting blood test
C. Synachten test
D. 24 hour urinary free cortisol-
../ (9 24 hour qexamethasone suppression

36. A 40-year old man presents with dehydr�ti_!ln. S�s a

history of !Ror_yn� and [polyqipsia.J f_asting_ blo·, d g :Gcose is
_?m_rr,9JJ. What is the single most appropriate in est:ig tion?
A. Random blood glucose
../, B Oral Glucose tolerance test
C. Dexamethasone suppression test fo
D. CT scan of the adrenal glands
E. Fasting blood glucose.

be obese.

,..eJ,dD�
co,,-
3'8. A 65-year old woman presents with rgf_urrent va inal itch.
She has a BMI of JJ.. Random blood glucose is 15mmol/.
---�-- What is
single mostlfk.ely diagnosis?
1

A. Type 1 diabetes mellitus , ,.

B. Cushing syndrome
C. Conn's disease
D. Impaired fasting blood glucose

12
.,,ro Type 2 diabetes mellitus
39. A 55-year old man presents with_gJycgsuri_�. He had an oral
glucose test. After .l_tlour his blood glucose i�_J _'!_lmol/l. What is
the single most likely diagnosis?

A. Diabetes type 1
,, B. Diabetes type 2
/@ ��ochromocytoma. \M()c,1�cd g\uco;;.t?.
D. Diabetes insipidus
E. Cushing syndrome

40. A .i 1-year old .'Ilan presents·with wei' loss. He has a raised

�_l9_od glucose concentration and ket, i . W; at is the single most
likely cause?
A. Glucocorticoid deficiency �
,/'B An absolute deficiency of i sulim}, r
C. An absolute excess of insa �p-
D. A relative deficie �� of i�sulin ( 1y pG �)
E. Decreased parat y. , 1 hormone

41. A 36-�e _ old woman presents with c_entral .ob�siJy, rnuscl�

wasting a af)aominal striae. She has a rai�ed blood glucose
cone,. tta ion'? What is the most likely cause(-- · ·· ·
cu::. i""�

B ncreased glucocorticoid
CS. ncreased catecholamine
D. Growth hormone deficiency
E. Deficiency of thyroxine

42. A 4__4-year old man presents with seizures. He has been found
to have low blood lucose. What is the single most likely cause?
13
. .::___ A,.
.,, An absolute excess of insulin

B. An increased Glucocorticoid
C. Increased parathyroid
D. Increased thyroxine
E. Starvation

43. A_?_D_-year Qld womc1n presents with 9���jty. She has a raise
blo9q_gluc;ose concentration but rt<? ketones. What is ti;\ - s-i. gle
most likely cause?
A. Catecholamine deficiency
B. Deficiency of thyroxine
C. Absolute deficiency of insulin
( D. A relative deficiency of insulin
- E. A relative deficiency of insulin

44. A 42.-year old man prese fs'

w· t:l �pi�99es__ Qf _pa!�or, �weati�g
and _b_ype_rte11�Jon. He h s r ,·,,, e • blood glucose concentration.
What is the single most like ¥ ssausei - . .. -·-·---· - -
r\\(0((0('{·0 r,· \()VY' 01

-year old woman found to hav the following results on a

�a;tine screen: ½,�lcium 2. 785 rfnol/ , Phosphate 0.8 mmol/l,
;<;

Al!:P 11..0 iu/l, PTH raised 25-OH Vitamin .D low/normal. What is

the single most likely underlying diagnosis?
A. Secondary hyperparathyroidism
B. Hyperparathyroidism
AC Primary hyperparathyroidism
D. Tertiary hyperparathyroidism

14
 E. Metastatic prostate cancer

46. A 25-year old woe an with reath[essnes calcium\2.9 mmol/l�

phosphate 0. 9mmol, ALP 70 iu/l, PTH low/normal,75-='0H ·vitamin-
-9-lgw R0r-maL, \25-QH vttamirf D -ig What is the single most
likely underlying diagnosis? r ,, • \
,ou,v�
A. Metastatic breast cancer)<
B. Multiple myeloma
C. Hyperthyroidism x..
D. Paget's disease of bone
./ E Sarcoidosis

47. A 35- e r old woman with bone pai , __sines and tbirst,
�calcium 3. � mmol/l, phosphate 0.75 mma' , _ALP 190 iu/lrJ PTH -�
low/normal, TH acti"ity l!l'ig , G_lu ose 6 mmol/l. What is the
single most likely underlying diag osis.
A. Thiazide diuretics 1-.

B. Hypoparathyroidism ;'
C. Sarcoidosis 1-­
.,1 D Metastatic breast cance
E. Multiple myeloma

�,t.d
�
48. A 70- e. r w.oman who has recently become WhE;?elchair
b.9und due to hip pgin: calciun,, 2� �5 �mmol/l, phosphate 0. 9
mmotr.t, · 750liu/l, PTH normal, 2��0H Vit�min D normal.
W, at · �h°elsingle most likely underlying-· diagnosis?
,'.) fl .. i q :l

· · ·get's disease of the bone ALP 't Co Ir "' Pceet·�

_.,.._,,.
B. Primary hyperparathyroidism
C. Thiazide diuretics
D. Hypoparathyroidism
E. Metastatic prostate cancer

15
 /?,
49. A 66-year old man with low back pain: calcium J..�.t�mi:nol/l,
phosphate 0.7 mmol/l, -ALP 120 �m'lt, ratJo
phosphate 310iu/l ·'j'
haemoglobin 9.0g/dl. What is the single most likely underlying
diagnosis?
A. Tertiary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Metastatic breast cancer
D. Hyperparathyroidism
{9 Metastatic prostate cancer o.c,d t' �o�p'1o-\ -e ./t·
1>
50. A 60-year old man with back Ra_in: Calciu ,' 3.0 , >mol/l,
phosphate 0.6 mmol/l, ALP 70'-.Yti'/l, Albumin 28 ,g'L--1.,. Total protein
L) 91 g/l, Haemoglobin .9..�0g/dl. What is the 3 gle most likely
underlying diagnosis? tiv\�'() 1\- 1 1r-

A. T hiazide diuretics
B. Sarcoidosis
J@) Multiple myeloma
D. Hyperthyroidism
E. Hypoparathyroidism

52. A 40-year old' Afro-Caribbea male presents with a �-�jr}gir,g

fever, {156fyd�psi� and ,,poly�r-:t� and gradual onset exertional
dyspnoea. In addition he has a month history of 11:Jni?roduc:tixg)

16
 \ coug and chest x-ray reveals bilateral hilar shadowing. What is
the most appropriate investigation?
A. Oral glucose tolerance c::,or co i do-1\ :i
B. Water deprivation I\'11 p(...,, (...
:'. "r!\C
' ... C"i\'·
. c...,
. ; ..,,

C. Echocardiography and blood cultures

D. Diuretics stimulation trial
J E Plasma calcium and;�CE levels

53. A _25-year woman presents with \intolerance fo El nd

sweating of pe hands. She has a smooth, soft thyr:©'.id swelling
with a[bruit What is the single most likely diagnosi ?
A. Inclusion cyst
....-® Thyrotoxic goitre
C. Hashimoto's disease
D. Follicular carcinoma of the thyroid
E. Drug induced thyrotoxicosis

54. A.52-year old woman dev@lo�sl a smooth swelling in the neck,

1sensitivity to cold) brady · dia and hair loss. Her blood count
shows a macrocytic nae What is the single most likely
diagnosis?-- \ c�c J'{l'
h19°''()
,/ A Hashimoto's di
B. Branchial , yst
C. Auto- immu �ypothyroidism
D. Ana p· aSI ·c c rcinoma of the thyroid gland

� Weight loss will result iILrn�toration of the function of

specific receptors and may allow all medication to be withdrawn.
What is the single most likely diagnosis?
A. Alcohol abuse
B. Cushing's syndrome
C. Hypothyroidism
,/ D Non-insulin dependent diabetes mellitus

17
 E . Menopause

56. Obesity and other clinical features will resolve following

surgery to remove the underlying cause . What is the single most
likely diagnosis?
/@ Polycystic ovary syndrome
B. Obstructive sleep apnoea
C. Mellitus (I DDM) (Type 1 diabetes)
D. Insulin dependent diabetes
E. Alcohol abuse

57. Obesity may occur in association 'th nutritional

deficienci�s. What is the single most likel� dli 0s1s?
�
A. Menopause �
B. Obstructive sleep apnoea
C. Cushing's syndrome
../i D Alcohol Abuse
E. Polycystic ovary syndrome

cure the disorder, improve daytime

tore marital harmony. What is the single most

59. A 70_�y_ear old woman presents with \.4lejghtg�in , lethargy and

cons_tipation. Her thyroid stimulating hormone TS.ti is noted as
twice� the upper limit of normal. What is the single most
appropriate next management step?

18
 A. Carbimazole
B. Fine needle aspiration biopsy
C Thyroxin Ci "i)
D. Observation only
E. Propranolol

60. A 33-year old woman presents wi th a sy_mptom lE:� goi e.

Her tb_yroig___ Ju.nc tion tests are_ norm.al and an ultraso d s am
shows no _suspicious_ features. What is the single most ap
next management step?
A. Radioactive iodine
B. Thyroid autoantibody assay
C. Thyroidectomy
·"{ID Observation only
E. Thyroxin

febrile
-�-·-- -illness.
--- -- Her 1s
enlarged. What is the single mos•
� t�p?
�
A. Ultra sound scanA ,eek
B. Thyroxin
C. Thyroide<; omy
(D) Observa·f·o r.1ly

6-year old woman is found to have a 2cm.. s..oU1ary nodule in

tQ,e l�ft loqe of the thyroid. What is the single most appropriate
nex t management step?
A. Carbimazole
B. Observation only
C. Propranolol
AD Ultra sound scan of neck
E. Radioactive iodine

19
 63. A 32-year old woman with recent history of weight _!Q,ss and
palpitations. Her thyrojg tests T3 and T4 are grossly raised and
she has an intermfffent tachycard.i� of 1'20 beats/minute. She has
a past history. of asthm�. What is the single most appropriate
n�xt management step?
A. Thyroid auto-antibody assay
hy peX' \ \ ( 0\ d (;, ·'\
Jt B Carbimazole
C. Thyroidectomy
D. Fine needle aspiration biopsy
E. Observation only

64. A female patient presents with amenor:rn · ea and eight ain.

On investigation, she has a low thyroxi · ·� lil ,a very a v..ery_ high
Jh_yrgid stimulating hormone level. ha is �fie most appropriate
management?
A. Observation only
B. Autoantibodies
C. Radioactive iodide
D. Thyroidectomy
./ E Thyroxine

N ,- ....
65. A pa .nt presents with ctremorJ and (palpations· She has a
histo,J¥ of st:nma. What is the most appropriate management?
A. Th oi'dectomy

E. Autoantibodies
)

20
 66. A patient has symptomless goitre. On investigation she is
euthyroid and on ultrasound scan there was no suspicious finding.
What is the most appropriate management?
A. Fine needle aspiration cytology (FNAC)
B. Autoantibodies
�-© Observation only
D. Propranolol
E. Thyroxine

�
67. A patient presents with a solitar.Y_ tbY.rQid _!!S>dule c, about 3�
c� in diameter. What is the most appropriate mana · ement?
/(5) Fine needle aspiration cytology (FNAC)
B. Observation only
C. Thyroxine
D. Radioactive iodide
E. Autoantibodies

68. A 40-year old woma, �j.th a 20 years history of type 1

diabetes mellitus pr:es nts with three week history of severe
bypoglyc_cl�r,nic episo es. :fhere has been no recent change in her
insulin therapy, d" o (evel of exercise. What is the single most
likely complicatio o diabetes mellitus?
a 1. neuropat
) hy

. Diabetic ketoacidosis
E Nephropathy ( rEduce ·,(,3(.)\·,l'\e\

69. A 60-year old man with t��-lLdiabetes mellitus, presents

with pr:_qgre.ssive dr�iness without focal neurological signs. He
has been treated with the �a111�-Qf9:Lh_ypggly{;a_emic drugs for live
years but has recently been found to have bYRe.r�r:-istQn for which
21
 a �it1;?:_iq_e dtur_etic has been prescribed. What is the single most
--
likelycomRli_cation of di���t�s _r:ne_lJj!:_us?
/(A. Hyperosmolar non-ketotic coma 1-1 \--LS
B. Hypoglycaemia
C. Irritable bowel syndrome
D. Proliferate retinopathy
E. Retinal detachment

70. A 40-year old man with a 30 year history of t . d7betes

mellitus OM is referred to the gastroenterology cli ic be ause he
has recently developed episodic tjiarrhoea. ·tia is the single
most likely complication of diabetes mellitus?
A. Transient ischemic attack (TIA)
B. Somatic neuropathy C poi
-· C. J\utonomic neuropathy C ...,,r
D. Coronary heart disease
E. Diabetic ketoacidosis

71. A 40-year old , an with a 20-year history of diabetes

mellitus presents beca s she has a number of recent episodes of
loss of consciousn�5s. hese have mainly occurred whHst waiting
for the bus honie'. She has checked her blood glucose and
ex.elude :;YP�gfycaemia. What is the single most likely
complic�, io of diabetes mellitus DM?

D. Irritable bowel syndrome

E. Hypoglycaemia

72. A 28-year old man with a 12 years history of type 1 diabete�

mellitus has �ddeo··total vis_ual los.s in his right eye. He has not
attended a general practitioner GP regularly, but appears well
22
 and had previous symptoms. What is the single most likely
complication of diabetes mellitus?
A. Hypoglycaemia
B. Transient ischemic attacks (TIA)
C. Somatic neuropathy
D. Diabetic ketoacidosis
/(1) Retinal detachment

73. An .§:year old boy is �qrni_tteo to a surgical ward fott0w1 � a

road traffic accident. He is found to have glycosuri . W'Jt'1 he
J

recovers from his injury the glycosuria resolves. Wt,. t is the

single most appropriate diagnostic test?
A. Detection of insulin antibodies
J@ Fasting blood glucose concentration
C. Estimation of blood glucose electrolyf
bicarbonate
D. Estimation of two hour post prandial
oncentration
E. Interval oral glucose

74. A 5-year old b0� attends with his mother, she is concerned
that he may hav dia , tes. He is asymptotic. What is the single
most appropriate ·agnostic test?
1

75. A 5-year old girl presents with a history of frequent faints

when she misses meals. She is concerned she may have diabetes.
What is.the-sfngle most appropriate diagnostic test?
A. Urinalysis for glucose and blood glucose concentration

23
 B. Urinalysis for glucose
C. Glycosylated haemoglobin
D. Urinalysis for ketones
.1'( E > Fasting blood glucose concentration
1,,-:,o\,C"\ \0vcl

76. A 12-year old boy with type 1 diabetes has poor long-ter .
control. He is admitted unconscious to the children's ward. H. 1
_hyperventilating and appears dehydrated. What is the single m, st
_approP.riate diagnostic test?
A. Interval oral glucose tolerance test
B. Random blood glucose concentration
/@Estimation of blood glucose electrolytes,
bicarbonate
D. Detection of islet cell antibodies
E. Urinalysis for ketones

77. A]S-year man consurn is aictor because of__? _�g_w.�tgJ,t loss

over four months. He is ea ing well and has developed diarrhQea
with no blood per r-ecttun. He is b.reathle.s.s and has a pulse rate
of 12.0 _betas/ ,.inut An electrocardiogram confirms atrial
fibrillation. Jugul r ¥enous pressure ,JVP is 11ot raised and lung
fields are cle. r. Wliat is the single most likely diagnosis?

78. A-60 year old man who has smoked since the age of _1 �
presents with severe, sudden lower thoracic spine pain. He has
lost weight. What is the single most likely diagnosis?
-
A. Depression
-/@Malignant disease
24
 C. Diabetes mellitus
D. Human immunodeficiency virus (HIV) infection
E. Starvation

79. A 17-year old �ch_ool girl is brought to the general practitioner

GP by her mother because of 10_!g Y{eight loss QYer sticmonths.
She has had no periods for. four months. The patient hersel 1

V
unconcerned about for her A level examination. What is
single most likely diagnosis?
.1i Anorexia nervosa
B. Vitamin 812 deficiency
C. Diabetes mellitus
D. Starvation
E. Crohn's disease

80. A 48-year old female insulin d. en y t diabetic who has been

on treatment for 20 years pres�ts( 1;1:h a history of} episodes of
severe _byp_qg_ly_ca�mia. S f h't not changed her insulin
requirement, diet or exe cis pa'ttern. What is the most likely
complication?

V
A. Hyperglycaemia �
B. Hypoglycaemi .....
C. Urinary tract in fion
./t D Diabetie ei;.lbfi pathy

8' • � 8-year old female insulin dependent diabetic who has been
Gm tr�atl}l_ent for 20 years presents with urinarY fre��ency but no
�y_suria _Qr urgency. Her blood glucose is 1Z��-"mmol/l. What is the
single most likely complication?
v A Autonomic neuropathy
B. Hyperglycaemia
C. Intermittent claudication

25
 D. Atherosclerosis
E. Atherosclerosis

82. A 30-year old female insulin dependent diabetic presents with

failure to pass urine. What is the most likely complication?
._/'(A..1 Autonomic neuropathy
B. Lactic acidosis
C. Ketoacidosis
D. Amyotrophy
E. Diabetic nephropathy

83. A 68-year old diabetic

i
on treatment for- tJie l t 5 years
presents with calf pafr )�_.?Cacerbated by m�Yemen!. What is the

��v
most likely complication?
�
A. Possible infection
B. Amyotrophic
C. Hyperglycaemia
../ D Intermittent claudicati r:i
E. Hypoglycaemia

84. A 70-year: old i oetic on treatment with me or · presents

with sever: p,i astric pain, drowsiness and confusion. What is
the most , ely complication?

85. A 4.9 years old .rnal� insulin dependent diabetic who has been
on treatment for 20 years is unable to achieve/maintain an
erection. What is the most likely complication?
26
 A. Intermittent claudication
B. Lactic acidosis
/'(t. Autonomic neuropathy
D. Possible infectio/
E. Atherosclerosis

--J> A. Possible infection

B. Lactic acidosis
C. Urinary tract infection
v'(� Am-yotrO�·l:iic 'c::.O!Y'O� \ C
E. Ketoacidosis

88. A 42-year old man is found at routine medical examination to

have a blood pressure of 170/ 12Q,mmHg. On questioning he
admits to bouts of diarrhoea several times a week. He has been
complaining of intermittent
__ .. ---· h.eadaches and pc:1lpitations for some
.,. ___., -- __ ,.__ . .. - ' - -- . . ... .

months. What is the single most abnormal?

27
 A. Thyroxin
./ .,, Adrenaline
C. Testosterone
D. Somatostatin
E. Glucagon / /
)
89. A 60-year old woman is found to have an elevated _calci m
level on a routine biochemical profile. Repeated measw eme ts
confirm the finding. What is the single most abnormal?
A. Prolactin
B. Glucagon
C. Aldosterone
D. Thyroid stimulating hormone (TSH)
/ ® Serum parathyroid hormone
90. A 40-year old man prese�t-s wr h - irst p9lyuri_a and marked
muscle w�a�n�ss. His blood JDJeSS9J e is !�..QL!10�mmHg. His serum
sodium concentration i. nor-m'al and his serum p_g_tas�iym
COl}��!JJraUon js Jqw. His dood glucose is normal. What is the
single most abnorma!1

9 . A 75-year old woman presents with p_gf<;>)'.<:y�n,gl _ noc:;turnal

�yspnqea. She is found to have �.trial fibrillatio,n. What is the
single most abnormal?
/� Thyroxin

28
 B. Insulin
C. Glucagon
D. Calcitonin
E. Prolactin

92.A 74-year old .�maker. presented to his GP with cough A'€!

Shortness of breath. Exam revealed (P'1gmenlaj:1on) of the �l
/ ..J.JCOSa)and also over the palms and soles. Tests show t e is
qiabetic and hypokalemic. What is the most probable dia ·ITTo;is.
a. Pseudo-Cushing syndrome
b. Conns disease
/@ Ectopic ACT H
o.\\ cQ\
-:- cc cQ I
tiJ("0
A, y
""- �

d. Cushing disease
e. Hypothyroidism

93.A 38-year old 1 tin ling, �umbness,

p_�resth�si.a, respiratory strider an� in o untary spasr:n of the
upper extremities. She has , , derg, e surgery for _thyroid
c:arcinoma a week ago. What is. t · most likely diagnosis?
a. Thyroid storm
b. Hyperparathyroidism G
c. Unilateral recurrent la r1geal nerve injury
d. External laryngea� er:ve 'njury
./@ Hypocalcemia

94. A 54-yea old w�oman has presented with episodes of

?bdomi _a, a he\ yomiting and postural hypotension. She also
has a_ aR pi mentatjq_n of her skin. A diagnosis of Addison's
di�ea.Sj as macie. What is the most likely electrolyte , \"y pni o .c\· ) ,·:,,
ab or�ality expected in this patient? 1.r--,1 p-er ,�-'\' ,.01 1
a. Hig Na+, Low K+ � r-� \ cc:;,f'\"',.)
A . o Na+, High K+ ¾
'
G. ow Na+, Low K+
a. High Na+, High K+
e. Low Na+, Normal K+

95.A 79-year old woman has been diagnosed with Type II Diabetes
Mellitus. Her BMl=22:-'Random blood sugars are 8 and 10mmol/
l. Her BP=130/80mmHg. Her fasting cholesterol=5.7mmol/l.
1�'5/.q5 "��0�

29
 She is currently symptom·free but has microalbuminuria. What
is the single most appropriate drug ma'nagement?
a. ACEI and glibenclamide
b. ACEI and metformin
../ c Statin and ACEI
d. Statin and glibenclamide
e. Statin and metformin

96.A 46·year old woman has weigb!___gain, ��r1sitivity to c · d,

ulse=:=_50bpm, heart is enlarged with murmur.
single most likely diagnosis?
A a. Hypothyroidism
. Hyperthyroidism
c. Cushing's syndrome
d. Addison's disease
e. Pheochromocytoma

97.A 43·year old woman has been feelin

BP=160/90mmHg. Bloods: Na+=j-40
What is the most likely diagnosis?
\,-,,y (Xi \"" n' r �" , ;
, a. Cushing's syndrome �
v·{ • Conn's syndrome
c. Hyperparathyroidism V [' 1\_, ,
d. Renal disease
e. Phaeochromocyto a

99. A patient was admitted with ff_eftH�-· dysfu.n.��Jon, r�duced

facial hair and galact9rrhea. What is the most probable
diagnosis?·
-/@Hyperprolactinemia
b. Cushing's syndrome
c. Phaeochromocytoma
d. Hyperthyroidism
30
 e. Hypoparathyroidism
100. A 62-year old man diagnosis with Type II diabetes mellitus
with BMl=33. Lifestyle modifications have failed to control
blood sugar. Labs: urea= 3.6mmol/l, creatinine"'.'B,9mmol/l.
what is the next appropriate management?
ca. Biguanide ( M€:�'(0( 1V'i�)
b. Sulfonylurea
c. Insulin
d. Glitazone
e. Sulfonylurea receptor binder

101.A patient with has a fundus showing i:nicro-aneurysm

hard exudate. What is the single most likely dx?
a. Macular degeneration
b. Hypertensive retinopathy
c. Multiple sclerosis
vta. Diabetic background
e. Proliferative Diabetic retinopathy
102.A y9_yr:,g_ J?9Y presents with graGfµa" · orsentng headaches,
visual disturbance, and l�c.!< of ene gy. MRI shows 15mm, tumor
in the pJtuitciry fo,5sa. What is t� t,r.eatment of choice?
a. Radiotherapy },-
b. Octreotide
c. Reassurance and follow ap> after
,, 6 months
"'@Surgery
e. Chemotherapy
103.A 54-year ol a_e patient DJ9b.�tes mellitus with BMl =33
who has been t eated using dj�t_ary . �on!_rol up till now
presents © hi� r.·p with a fasting blood sugar of J4r,nmol/l and
creaU : = )0mmol/l. Urine shows glyf.QSJJ[ja. No other
abnor · a �ties are found. What is ttie best next step in
an gement?
A a. Bi a-ide
�- . &uJronylurea
c. nsulin
d. Sugar free diet
e. ACEI

31
,