1. Question Category: Endocrinology A74-year-old male has been diagnosed with type 2 diabetes mellitus for last 15 years. He has been on metformin and gliclazide. He has recently been started on insulin because of the poor glycemic control. He is worried about hypoglycemia as it can happen with insulin therapy. Which of the following increases the risk for development of hypoglycemia? © Renal failure © Excessive carbohydrate intake Oo Reducing alcohol ingestion Ceasing Metformin Oo Ceasing Gliclazide Skip question Oo BN fon nt)able Ceasing Metformin Ceasing Gliclazide Correct Hypoglycemia is a common side effect of insulin therapy. The factors which can increase the risk of hypoglycemia in diabetes patients include: -Deficient carbohydrate intake -Renal failure -Excessive alcohol ingestion -Continuing sulphonylureas such as gliclazide, with insulin. Metformin does not cause hypoglycemia. Excessive carbohydrate intake, as needed, reducing alcohol ingestion and ceasing gliclazide will reduce the risk of hypoglycemia. References: al) https://www.nebi.nim.nih.gov/pmc/articles/PMC 4265808/ TAKE NOTES Ul «Category: Endocrinology Mrs Johnson with underlying hypothyroidism and uncontrolled type 1 diabetes mellitus, now presents to your clinic with worsening shortness of breath since last few months. You know her since last five years, and she has not seen you for a year. She also complains of excessive sweating, oily skin and headaches quite often-You noticed a change in her personality like coarse facial appearance, spade-like hands, large tongue.There is no visual change reported. What is the BEST diagnostic test for this patient? © Echocardiography © Pituitary MRI O Serum IGF-1 © Chest X-ray Oral glucose tolerance test with serial GH measurements TAKE NOTES © Ul O c4ava sae @ member.mplusx.com/quizz ic) Correct Acromegaly results from persistent hypersecretion of growth hormone (GH). Excess GH stimulates hepatic secretion of insulin-like growth factor-1 (IGF-1), which causes most of the clinical manifestations of acromegaly. The clinical diagnosis is often delayed because of the slow progression of the signs of acromegaly over a period of many years. This patient has signs and symptoms of acromegaly. These include: - Coarse facial appearance. - Spade-like hands. ~ The increase in shoe size. - Large tongue. - Prognathism. - Excessive sweating and oily skin. - Features of pituitary tumour(hypopituitarism,headaches, bitemporal hemianopia). Complications of acromegaly include: - Hypertension. ~ Diabetes mellitus. - Cardiomyopathy. ‘oloret a. NOLL) diag! mica’‘Complications of acromegaly include: - Hypertension. ~ Diabetes mellitus. - Cardiomyopathy. - Colorectal cancer. The diagnosis of acromegaly is a biochemical one and does not require the presence of typical phenotypic features or the presence of a pituitary tumor on magnetic resonance imaging (MRI). Therefore, biochemical testing of anyone with a clinical picture suggestive of acromegaly (eg, pituitary tumor of any size or signs and symptoms of acromegaly) is essential. In genearal, the best single test for the diagnosis of acromegaly is measurement of serum insulin- like growth factor-1 (IGF-1). Unlike GH, serum IGF-1 concentrations do not vary from hour to hour according to food intake, exercise, or sleep, but instead they reflect integrated GH secretion during the preceding day or longer. Serum IGF-1 concentrations are elevated in virtually all patients with acromegaly and provide excellent discrimination from normal individuals. BUT in this context, the patient has both poorly controlled type 1 diabetes and hypothyroidism. It may produce equivocal serum IGF-1 cent! ber of, a br Caaot3 dliti er sel IGF-1 concentrations, including hypothyroidism,ISOS ee ee | @ member.mplusx.com/quizz ic) BUT in this context, the patient has both poorly controlled type 1 diabetes and hypothyroidism. It may produce equivocal serum IGF-1. concentration result. (There are a number of conditions that are associated with lower serum IGF-1 concentrations, including hypothyroidism, malnutrition, poorly controlled type 1 diabetes, liver failure, renal failure, and oral estrogen use.) Hence, in these situations, it is possible that the diagnosis of acromegaly could be missed, and an oral glucose tolerance test (OGTT) with serial GHis the BEST diagnostic test and should also be performed if the disorder is suspected. The most specific dynamic test for establishing the diagnosis of acromegaly is an OGTT. When performing the test, serum GH is measured before and two hours after glucose administration; the criterion for the diagnosis of acromegaly is a GH concentration greater than 1 ng/mL. In normal subjects, serum GH concentrations fall to 1 ng/mL or less within two hours after ingestion of 75 g glucose. In contrast, the post-glucose values are greater than 2 ng/mL in| th a TAKE NOTES meg} The pituitary MRI may demonstrate a pituitary Ul «ceed A 43-year-old woman presents to your office with a history of insomnia and palpitations. She also reports the history of weight loss and issues with anger management. On examination, she has sweaty palms. Her heart rate is 110 beats per minute and there is fine tremor of the both hands. Which of the following is the most appropriate next choice of investigation to confirm the diagnosis? © TSH receptor antibodies © FreeT4 O FreeT3 © TSH © Anti-thyroid peroxidase TAKE NOTES ©hae Correct This patient has developed clinical features of thyrotoxicosis and needs further investigations. The serum TSH (thyroid stimulating hormone) is the most sensitive index of thyroid function test. This is a preferred initial test for suspected thyroid dysfunction. If necessary, repeat TSH in 3-6 months. When the TSH is normal, it is rare that a patient is thyrotoxic. Thyroid autoantibodies (anti-thyroid peroxidase, anti-thyroglobulin, TSH receptor antibodies) are performed if thyroid dysfunction is proved based on clinical history, examination and TSH levels. The level of these antibodies is elevated in Grave's disease. References: il https://www.mja.com.au/journal/2004/180/4/5 -diagnosis-and-management-hyperthyroidism- and-hypothyroidism 2/ https://www.racgp.org.au/afp/2012/august/eval uating-and-managing-patients-with-ai teed 9 4. Question Category: Endocrinology An 18-year-old girl presented with delayed puberty.She is at Tanner stage 2 now.Which of the following is the initial investigation of choice in this situation? oO O Bone age Serum FSH and LH level Thyroid function ESR Chromosomal analysis Skip question TAKE NOTES ©shoe aie Bee @ member.mplusx.com/quizz ic) Correct This patient presented with delayed puberty whichis arrested at Tanner stage 2. Tanner stage 2 is usually seen in girls between 9 to 13 years of age and Tanner stage 5 is seen at 16 years old. There is a five-year pubertal delay in this patient and needs to be investigated. The most common cause of the pubertal delay is. aconstitutional delay of growth and puberty (CDGP). The initial choice of investigation is to determine bone age by doing an X-ray of left wrist and left hand. A radiograph of the left hand and wrist to evaluate bone age should be obtained at the initial visit to assess skeletal maturation and repeated over time if needed. This provides valuable information about the relationship between chronologic age and skeletal maturation, the potential for future skeletal growth, and allows a preliminary prediction of adult height. These results are useful when making decisions about possible interventions (eg, whether or not to initiate BGP).aoe Cae skeletal maturation, the potential for future skeletal growth, and allows a preliminary prediction of adult height. These results are useful when making decisions about possible interventions (eg, whether or not to initiate hormonal therapy for patients with CDGP). However, the bone age does not help to distinguish between different causes of delayed puberty. Patients with CDGP typically have bone ages delayed by approximately 20 percent compared with chronological age. Skeletal development progresses slowly without the presence of pubertal levels of gonadal steroids because sex steroids are required for epiphyseal closure. Bone age is usually delayed in constitutional delayed puberty and is normal in Turner’s syndrome. Delayed puberty is defined as lack of pubertal development by 14 years old for girls and age 15 for boys. As this patient has started pubertal development and it is arrested at Tanner stage 2, it is unlikely due to hormonal disorder. However, if bone age determination is not helpful, an endocrinologist may consider doing serum FSH, LH, prolactin, thyroid function tests and chromosomal analysis. i TAKE NOTES eterended eee | Quiz Summary 5. Question Category: Endocrinology Which one of the following is the best screening test for systemic lupus erythematosis? O _) ENA antibodies © Rheumatic factor © dsDNA antibodies O ANA © ESRand CRP Skip question TAKE NOTES ©vad ESR and CRP Correct In suspected clinical diagnosis of systemic lupus erythematosis (SLE),ANA (anti-nuclear antibodies) level is used as a screening test.It is positive in 95 percent case. The level of dsDNA antibodies and ENA antibodies is tested if ANA is positive to confirm the diagnosis of SLEThe dsDNA has specificity of 90 percent for SLE and sensitivity of only 60 percent. Rheumatic factor is positive in 50 percent of the cases and is not used as screening test.ESR and CRP is elevated in proportion to disease activity.These are very non-specific test to perform. References: 1/https://www.racgp.org.au/afp/2013/october/s ystemic-lupus-erythmatosus/ 2/https://www.racgp.org.au/download/Docume nts/AFP/2013/Oct/201310apostolopoulos.pdf Ba TAKE NOTES rovad 6. Question Category: Endocrinology A 34-year-old male presented with a gradually increasing size of hands and feet, mandibular enlargement and macroglossia. Which of the following is the most appropriate screening test to assess this patient? O, Serum cortisol level ) Insulin-like growth factor 0 Random growth hormone level © Free T4 level © Thyroid stimulating hormone Skip questior TAKE NOTES oadahve ie Correct This patient has developed clinical features of acromegaly. The clinical features of acromegaly include frontal bossing, increased hand and foot size, mandibular enlargement with prognathism, and widened space between the lower incisor teeth, characteristic coarse facial features, and a large fleshy nose. Generalized visceromegaly occurs, including cardiomegaly, macroglossia. Acromegaly results from persistent hypersecretion of growth hormone (GH). Excess GH stimulates hepatic secretion of insulin-like growth factor 1 (IGF-1), which causes most of the clinical manifestations of acromegaly. An IGF-I level provides a useful laboratory screening measure when clinical features raise the possibility of acromegaly. Due to the pulsatility of growth hormone secretion, measurement of a single random GH level is not useful for the diagnosis or exclusion of acromegaly and does not correlate with disease severity. Also, another test called Growth hormone suppression test is also performed for confirmation of aeT eee | Quiz Summary 7. Question Category: Endocrinology Which one of the following drug is not associated with gynecomastia? O -) Methyldopa .) Frusemide oO Oo ©. Spironolactone © Cyproterone O Digoxin Skip question TAKE NOTES ©aoe aie Incorrect Gynecomastia, a benign proliferation of the glandular tissue of the male breast, is caused by an increase in the ratio of oestrogen to androgen activity. It may be unilateral or bilateral. In 10-25% of the cases, drugs are considered as the primary cause of gynecomastia. Spironolactone can increase the aromatization of testosterone to oestradiol and decrease the testosterone production rate by the testes. Other drugs which are commonly associated with the development of gynecomastia include: 1-Digoxin 2-Methyldopa 3-Cyproterone 4-Cimetidine 5-Ketoconazole 6-Finasteride 7-Alcohol 8-Haloperidol 9-Isoniazid 10-Anabolic steroids. Frusemide is a loop diuretic and is not associated with the development of gynecomastia. Referenq TAKE NOTES https://wwweneDiminmn.gov/pmerarticles/PI Ul «In 10-25% of the cases, drugs are considered as the primary cause of gynecomastia. Spironolactone can increase the aromatization of testosterone to oestradiol and decrease the testosterone production rate by the testes. Other drugs which are commonly associated with the development of gynecomastia include: 1-Digoxin 2-Methyldopa 3-Cyproterone 4-Cimetidine 5-Ketoconazole 6-Finasteride 7-Alcohol 8-Haloperidol 9-Isoniazid 10-Anabolic steroids. Frusemide is a loop diuretic and is not associated with the development of gynecomastia. References: Vv https://wwwncbi.nim.nih.gov/pmc/articles/PMC 4412434/ a TAKE NOTES rd8. Question Category: Endocrinology A 21-year-old tall male presented with decreased facial and axillary hair growth, decrease libido. On examination, he had decreased penile length, small testes and gynecomastia. He had learning difficulties asa child. Heis at risk of developing all of the followings except? © Thromboembolic disease © Autoimmune thyroid disease Breast tumour Oo Oo Varicose veins Diabetes mellitus Skip question a TAKE NOTES Ooaioe Cee F: Incorrect This patient has clinical features of Klinefelter syndrome. It is chromosome XXY abnormality due to meiotic nondisjunction. Main features include tall stature, small testes, small penis, gynecomastia, decreased facial and axillary hair growth and decreased libido. These patients are at high risk of following complications: -Breast tumours. -Thromboembolic disease. -Obesity. -Type II diabetes mellitus. -Varicose veins -Learning disabilities Autoimmune thyroid disease has an association with Turner's syndrome instead of Klinefelter syndrome. References: Vv https://www.healthymale.org.au/sites/default/fil es/resources/klinefelter_syndrome_- _hormones_and_me_guide.pdf a TAKE NOTES rd9. Question Category: Endocrinology A32-year-old male developed high blood pressure which has not responded to ramipril, metoprolol and amlodipine. His blood is 180/105 today. Blood test shows hypokalemia. Patient's father died of a subarachnoid haemorrhage at the age of 36 due to severe hypertension. What is the most appropriate next step in his management? © 24-urinary steroid profile O ©) Adrenal vein sampling O Give spironolactone © Measurement of aldosterone-renin ratio © Un-enhanced CT of adrenal glands Skip question TAKE NOTES _ oadaioe corre This patient has clinical features of mineralocorticoid excess and the most appropriate next step is to measure aldosterone-renin ratio to confirm it. Excess activation of mineralocorticoid receptors leads to potassium depletion and increased sodium retention leading to expansion of plasma volume and extracellular fluid volume. Also, increased extracellular sodium leads to hydrogen depletion resulting in metabolic alkalosis. Aldosterone-renin ratio should be requested if patient fulfils following criteria: -Severe hypertension resistant to 3 antihypertensive drugs. -Hypokalemia. -Adrenal mass or -A family history of early onset hypertension or cerebrovascular events less than 40 years of age. The next step would be saline infusion test and if that is positive, CT scan of adrenal glands should be organised. All other options are incorrect. References: TAKE NOTES octol urrent-pattern-of-primary-aldosteronism- Ul «Bane eee | aise ied Quiz Summary 10. Question Category: Endocrinology Hypercalcemia is not associated with which one of the following conditions? O _) Sarcoidosis -) Secondary hyperparathyroidism O Oo ©) Leukaemia © Vitamin D overdose © Hyperthyroidism Skip question TAKE NOTES ©Vitamin D overdose Hyperthyroidism Correct Common causes of hypercalcemia include: ~ Sarcoidosis. - Malignancies like lymphoma, leukaemia. - Hyperthyroidism. - Vitamin D overdose. Secondary hyperparathyroidism occurs in patients with vitamin D deficiency, renal failure and osteomalacia. Hypocalcaemia seems to be the common denominator in initiating the development of secondary hyperparathyroidism. References: al) https://www.ncbi.nim.nih.gov/books/NBK2791 29/ TAKE NOTES