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    Prof. of Hepatology & Gastroenterology, Cairo University.

    Consultant of Hepatology,Gastroenterology and Endoscopy

    Management Positions: •

    Chief of Hepatology unit El Manial University Hospital (1994-1998).

    • Chief of Gastroentero ICU in Cairo university hospital (1997-2000)

    • President of the board of AlfaScope GI Specialized center (2004-2014).

    • Head of Endoscopy Unit in Cairo University Hospitals (2005-2010).       

     

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    استاذ الكبد و الجهاز الهضمى بكلية الطب جامعة القاهرة

    استشارى الكبد و الجهاز الهضمى و المناظير

    دكتوراه امراض الكبد و الجهاز الهضمى من كلية الطب جامعة القاهرة

    الرئيس السابق لقسم الامراض الباطنية بكلية الطب جامعة ٦ اكتوبر

    الرئيس السابق لوحدة مناظير الجهاز الهضمى و مركز الكبد و الرعاية المركزة بقصر العينى

     

    إقرأ المزيد

     

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Wednesday, Aug 23rd

Last update10:09:06 AM

        

Endocrinology

Endocrinology

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Endocrinology

 

Enumerate:

1. Complications of diabetes mellitus.

1. Skin complications of DM.

2. Cardiovascular complications of DM.

3. Neurological complications of DM.

4. Urogenital complications of DM.

5. GIT, respiratory & ocular complications of DM.

6. Causes of coma in a diabetic patient.

7. Indications to use insulin in treatment of DM.

8. Adverse effects of insulin.

9. Adverse effects of oral hypoglycaemic drugs.

10. Causes of hypoglycemia.

11. Causes of obesity.

11. Complications of obesity.

12. Cardiovascular manifestations of hyperthyroidism.

13. Ocular manifestations of hyperthyroidism.

14. Cutaneous & neurological manifestations of hyperthyroidism.

15. Adverse effects of anti-thyroid drugs.

16. Causes of hypothyroidism in adults.

17. Cardiovascular manifestations of hypothyroidism.

18. Neurological manifestations of hypothyroidism.

19. Cutaneous & GIT manifestations of hyperthyroidism.

20. Causes of polyurea.

21. Causes of stunted growth.

22. Causes of secondary diabetes mellitus.

23. Hypercalcemia, how could you treat it?

24. Hypocalcemia.

25. Causes of  tetany.

26. Causes of  adrenocortical insufficiency.

27. Side effects of metformin.

28. Causes of acute adrenocortical insufficiency.

29. Laboratory tests for hyperthyroidism.

30. Endocrinal causes of hypertension.

31. Extra-pancreatic endocrinopathies, that may be associated with hyperglycemia  

 


Outline:

1. Diabetic nephropathy.

2. Diabetic neuropathy.

2. Treatment of diabetic peripheral neuropathy.

3. Etiology & Clinical picture of diabetic ketoacidosis.

4. Treatment of diabetic ketoacidosis.

5. The clinical picture & treatment of hypoglycemic coma.

6. Oral hypoglycemic drugs.

7. Indications & Adverse effects of Insulin.

8. Diagnosis & treatment of hypothyroidism in adults.

9. Diagnosis of hyperthyroidism.    

10. Treatment of Grave’s disease.

11. Thyrotoxicosis during pregnancy.

12. Clinical picture & treatment of thyrotoxic crisis.

13. Laboratory diagnosis of Cushing’s syndrome.

14. Treatment of hypercalemia.

15. Causes, diagnosis and treatment of Addisonian crisis.

16. The dietary prescription for a 45 years old type II diabetic patient.   

17. Treatment of type II diabetes.

18. Clinical picture & investigations of primary hyperparathyroidism.

                                          


Case 1:

A known diabetic patient was brought to the hospital in coma.

      1. Enumerate the probable causes.

2. How would you differentiate between the 2 most common causes of coma in a diabetic patient aged 18 years?

 

Case 2:

      A woman aged 55 years old, her weight is 95 kg & her height is 160 cm. She was discovered by chance to be diabetic.

      1. What are the laboratory criteria for diagnosis of DM?

      2. Discuss oral anti-diabetic drugs.

      3. Describe one method by which you can know if she is obese.

      4. Discuss the complications of obesity.

 

Case 3:

      An obese middle aged man presented to the clinic with a fasting blood sugar of 108 mg/ dl, and a 2 hours post-prandial of 186 mg /dl.

1. Define his glycemic state.

2. What are the lines of management at this stage?

Five years later, he developed frank diabetic symptoms, his fasting blood sugar increased to 188 mg/ dl, and 2 hours post-prandial sugar was 294 mg /dl

3. How would you treat him? (investigations not needed but details of drugs used is needed).

4. Mention five investigations you would like to do, and state the clinical relevance of each of them.

During the next five years, he was not compliant to his medications, despite having laser treatment for his left eye twice, and in the last few months he noticed edema of his lower limbs.

5. What is the probable cause of his edema?

6. How does this event influence your management?

 

Case 4:

A 30 years old female, pregnant in her 14 weeks, developed tremors, insomnia, intolerance to hot weather and loss of weight. On examination, she had tachycardia and wide pulse pressure.

1. What is the possible diagnosis?

2. How would you investigate it?

3. How to manage the condition in view of her pregnancy?

 


Case 5:

An 18 years old female is brought to the emergency room by her mother because she seems confused and is behaving strangely. Her mother reports that the patient has always been healthy, and has no significant medical history, but has lost 10 kg recently without trying, and has been complaining of fatigue for 2-3 weeks. She has been getting up several times at night to urinate recently. This morning the mother found the patient in the room complaining of abdominal pain and she had vomited. She appeared confused. On examination, the patient is thin, lying on a stretcher with her eyes closed, but is responsive to questions. She is afebrile, her heart rate is 118 bpm, with a blood pressure of 100/70, and is breathing deeply 24 times per minute. Her fundud examination is normal, her oral mucosa is dry, and her neck veins are flat. Her chest is clear to auscultation, and her heart is tachycardic with a regular rhythm and no murmurs. Her abdomen is soft with active bowel sounds and mild diffuse tenderness, but no guarding or rebound. Her neurological examination revealed no focal deficits. Laboratory studies include; serum sodium 131meq/L, potassium 5.3 meq/L, urea 70 mg/dl, creatinine 1.3 mg/dl, and glucose 475 mg/dl, arterial blood gases shows a PH 7.12, urine analysis shows no hematuria or pyourea, but 3+ glucose, and 3+ ketones. Chest radiograph is read as normal, and plain film of the abdomen has no specific gas pattern, but no signs of obstruction.

 

1. What is the most likely diagnosis?

2. What is the immediate treatment?

3. What is the long term management?

 

Case 6:

A female patient 25 years old, started to have palpitation, sweating, loss of weight, nervousness, fine tremors of both hands and swelling in the lower part of the front of the neck.

 

1. What is the possible diagnosis?

2. How can you prove your diagnosis by investigations?

3. What are the possible complications in such case?

 


Case 7:

A male diabetic patient 30 years old who received his usual insulin therapy in the morning, but he neglected to take his breakfast, short time later he got blurring of vision, irritability, excessive sweating, then he passed into coma.

 

1. What is the diagnosis?

2. How can you prove your diagnosis?

3. How can you treat this patient?

4. What are the possible other causes of such diagnosis?

 

Case 8:

A male patient aged 72 years, living alone, has diabetes mellitus since 35 years, receiving daily insulin 40 units before breakfast (a mixture of short acting and intermediate acting insulin). His daughter went to visit him at 2:00 pm, during the feast holiday, where she found him semi-comatosed & dysarthric, with marked sweating & tremors, and she noticed that his heart is beating vigorously.

 

1. What is your diagnosis?

2. Discuss the first line of treatment done at home.

3. Explain the causes of these signs observed by his daughter.

4. How could you confirm your diagnosis by laboratory means?

5. Enumerate other causes of such a condition.

 

Case 9:

A male patient aged 55 years, known to be diabetic for 30 years, presented to the hospital complaining of swelling of both lower limbs of 4 weeks duration.

General examination revealed;

- Generalized edema including face & upper limbs, together with ascites.

- Pulse rate: 79 beats per minute.

- Temperature chart: normal.

- No organomegaly could be detected clinically.

 

1. What is your possible diagnosis?

2. How could you investigate this patient?

3. What are the lines of treatment of this patient?

 


The edema decreased gradually with treatment, until it finally disappeared, and the patient was discharged for follow up in the outpatient clinic, and diuretics were withdrawn. Four years later, the patient came back with marked ill health, generalized bone aches, headache, blurring of vision, nocturia, polyurea, and parasthesia of both upper and lower limbs, together with vomiting and hiccups.

On examination:

- Blood pressure was 200/120.

- Respiratory rate was 30/m and deep.

- Marked pallor.

- Glove and stocking hyposthesia.

 

4. What is your diagnosis of the current problem?

5. How could you explain the following findings:

    - Abnormal breathing.

    - Glove and stocking hyposthesia.

 

Case 10:

A 56 year old male patient presented to the emergency room with chest pain of  3 hours duration. He used to have similar episodes over the past 6 months, but with increasing frequency and severity. On examination, he looked underweight, apprehensive, staring, flushed and sweaty. There was a bilateral and symmetrical fine tremors in his outstretched hands. Radial pulse rate was 130 bpm, while the heart rate counted over the apex was 150 bpm. Blood pressure was170/50. Examination of the neck showed congested veins with absent (a) waves. There was an olive-size smooth swelling to the right of the trachea that freely moved up and down with deglutition.

 

1. What is the most likely diagnosis?

2. What would be the pathogenesis of his chest pain?

3. How would you explain the described abnormal physical signs?

4. What would you expect to see on examination of his eyes?

5. What investigations would you require to confirm your diagnosis?

6. outline your immediate and subsequent treatment plans for this case.

 


Case 11:

26 year old woman, complains of irregular menses, obesity & low back pain. Examination revealed central obesity, abdominal striae, acne, hirsutism and the average BP in 3 occasions was 160/110.

 

1. What is the most diagnostic investigation for this case?

2. Mention one method to diagnose that a person is obese.

3. Enumerate causes of obesity.

4. Enumerate complications of obesity.

 

A low dose dexamethazone suppression test causes no suppression on urinary hydroxycorticosteroids. A high dose dexamethazone suppression test causes greater than 50% suppression of urinary hydroxycorticosteroids.

 

5. What are the expected changes in CBC of this patient?

6. What are the expected findings in skull x-ray for this patient?

7. What are the expected findings in chest x-ray for this patient?

8. What is the expected level of ACTH in this patient?

9. What are the expected findings in CT abdomen in this patient?

10. What are the expected findings in Ct skull in this patient?

11. What are the expected levels of serum Na & K in this patient?

12. What the expected levels of blood glucose in this patient?

13. Would this patient develop hyper-pigmentation or not?

14. How would you treat this patient?

15. Enumerate causes of hirsutism.

 

The patient was treated surgically. Few months later, the patient began to complain of persistent headache and change of the color of his skin. Examination revealed bilateral affection of the temporal field of vision.

 

16. What was the surgical intervention?

17. Explain the new developments in the patient’s condition.

18. What other manifestations may develop in this patient?

 


Case 12:

50 year-old female was seen because of lethargy & weakness for a period of about one year.

On examination the patient had:

- A sallow complexion.

- Puffy eyes.

- Cold and dry skin.

- Distended neck veins at a 45° angle.

- Distant heart sounds.

- Normal lung.

Chest X-ray revealed an enlarged cardiac shadow.

 

1. What are the most likely possibilities of diagnosis?

2. What are the investigations to be done to reach diagnosis?

 

Urine examination revealed:

- Volume: 1300 ml/24 hours.

- Specific gravity: 1016.

- Protein: trace.

- WBCs: 3-5/HPF.

- RBCs: 3-5/HPF.

- Crystals: few calcium oxalates.

3. What is the most likely diagnosis of the case?

4. What are the possible causes of this disorder?

5. Explain each of the previously mentioned physical signs.

6. Describe the full clinical picture of this disorder.

7. What are the expected findings in the ECG in this patient?

8. What is the most diagnostic investigation for the cardiac affection?

9. What is the pathogenesis of cardiac affection in this case?

10. What are the possible CBC results in this patient?

11. What is the expected cholesterol level in this patient?

12. How would you treat this patient?

 

The patient neglected the treatment. One day he was taken to the hospital unconscious.

 

13. What is the precipitating factor for this new event?

14. What is the other disorder that causes unconsciousness precipitated by this factor?

 

Case 13:

 A 30 year-old female was seen because of frequent headaches. On examination her blood pressure was 150/100 mm Hg. Fundus examination was negative as was the rest of the physical examination. There was no family history of hypertension.

1. Enumerate causes of hypertension.

 

Laboratory data were:

- Blood urea 15 mg/dl & serum creatinine 0.5 mg/dl.

- Serum Na 160 meq/liter & K 2.5 meq/liter.

2. What is the most probable diagnosis of the case?

3. What is the expected volume of urine in this patient?

4. What are the ECG findings in this case?

 

The patient experienced two attacks of muscle spasms.

5. What is the explanation of these muscle spasms?

6. What is the diuretic that would correct the electrolyte abnormalities?

 

Case 14:

A 32 year-old man sustained a mid-shaft humeral fracture after very slight exertion. X-ray showed the fracture to be through a bone cyst and other films showed wide-spread bone cysts in other bones. The abdominal film showed multiple bilateral kidney stones.

 

1. What is the most likely diagnosis?

2. Describe other clinical features and investigations of this disorder.

3. Enumerate causes of hypercalcemia.

4. Enumerate causes of hypocalcemia.

 

Case 15:

A 40 year-old male, comparing pictures for himself over the past few years, noted marked changes of his facial features, which became coarse. Recently he was complaining of annoying headache and pain in the knees. He went to a doctor for check up. His blood pressure was 150/100 and the doctor detected a bitemporal hemianopia.

 

1. What is the most probable diagnosis?

2. How to prove your diagnosis by investigations?

3. What are the possible neurological complications of this disorder?

 

The level of growth hormone was found to be high.

 

4. How to treat the patient?

Case 16:

A 25 year old pregnant female developed severe post-partum haemorrhage which was successfully controlled. The baby was artificially fed as his mother’s breast failed to secrete milk. The mother began to feel weak and she noticed atrophy of her breasts.

 

1. What is the most probable diagnosis?

2. What is the expected BP of the patient?

3. Do you expect the mother to become dark in color?

4. What is the expected menstrual disturbance?

5. How to prove your diagnosis by investigations?

 

Three drugs were prescribed after the results of investigations were known, but the patient started only by one of them, in order not to distress her stomach. Next day the patient complained of severe abdominal colics, vomiting and diarrhoea. Her blood pressure was dropping rapidly and she became irritable and confused.

6. What is your diagnosis?

7. How to prove it?

8. How to manage the case?

 

Case 17:

 A 22 year old female, complains of weight loss of one year duration.

 

1. What are the possible causes of weight loss?

 

On enquiring, she has good appetite, palpitations that increase with exertion and diarrhoea.

- No history of fever, polyurea or cough.

- She is having regular menstrual cycles.

On examination:

- Pulse: 120 beats/minute, irregular & most of the beats have high volume.

- Warm hands.

- Fine tremors in the hands and tongue.

 

2. Enumerate causes of tremors?

3. What are the possible causes of the mentioned case?

4. What other signs you would search for?

5. What do you expect to find in auscultation of the heart?

   

 

One day, the patient got marked palpitation, tremors, fever and sweating.

- Pulse: 170 beats/minute.

- BP: 170/80.

- Temperature: 38 C.

 

7. What is your diagnosis?

8. What are the precipitating factors?

9. How would you treat this condition?

10. What are the lines of treatment of this girl?

11. Which lines you prefer? Why?

12. One of your colleagues preferred to treat her medically, discuss the medical treatment.

 

The patient was maintained on medical treatment, after few months of treatment, she came complaining of cough, sore throat and fever.

 

13. What do you expect?

14. Describe the lesions you may find in the oral cavity.

15. How would you confirm the diagnosis?

16. How would you treat the case?

 

After improvement of the problem, it was decided to be operated upon.

After the operation was done, her general condition improved, she gained weight, but she started to have excessive lacrimation, parasthesia, exophthalmos and attacks of spasm of her hands and feet.

 

17. What is your diagnosis?

18. What are the causes of these spasms?

19. How would you confirm the cause?

20. What are the lines of treatment?

21. What is the cause of these eye manifestations?

22. What are the types and pathogenesis of ocular lesions in this disease?

23. How would you test it?

 


Case 18:

A 30 year old male went to the outpatient clinic complaining of general weakness, ill health, cramps, faintings and darkening of skin.

Examination revealed:

- Dark skin and mouth.

- BP: 100/70 while lying down and 80/50 after standing for one minute.

1. Comment on BP.

2. What is the most likely diagnosis?

3. What are the investigations needed to prove your diagnosis?

4. What are the possible ECG findings in this patient?

5. What is the cause of darkening of the skin?

6. What are the common causes for this disorder?

7. How to manage this patient?

 

The patient neglected the treatment. Few moths later the patient developed severe abdominal colics, diarrhoea and vomiting. He deteriorated rapidly and was transferred to the hospital with blood pressure 50/30.

 

8. What is your diagnosis? How to prove it?

9. What are the possible precipitating factors for such an event?

10. How to manage the patient at this point?    

Case 19:

A 35 year-old female complains of recent weight loss, in spite of a good appetite and of waking up frequently at night to urinate.

Examination revealed no abnormal physical findings. The patient’s weight was 80 kg and her height was 160 cm.

1. What is the most likely diagnosis?

2. How to establish the diagnosis?

 

The only abnormality found in random urine analysis, was presence of sugar.

3. Is presence of sugar in urine is diagnostic of diabetes mellitus?

4. What are the causes of presence of sugar in urine?

5. What are the causes of absent sugar in urine in a diabetic patient?

 

Fasting blood glucose was found to be 170 mg/dl and 2 hours post prandial was 265 mg/dl.

6. How to manage the patient?

7. How to follow up the patient to insure good control of diabetes?

 

The patient visited her doctor 2 months later for follow up.

- Fasting blood glucose was 120 mg/dl.

- Two hours post-prandial glucose was 140 mg/dl.

- Her glycosylated hemoglobin was 10%.

 

8. Is diabetes is well controlled in this patient or not?

 

The patient went to a gastroenterologist few months later complaining of one month duration, of pain in the epigastrium which increases after eating. She told the doctor, that she is having also bouts of diarrhoea every now and then which respond to oral antibiotics.

 

9. How to manage the epigastric pain?

10. What is the explanation of these bouts of diarrhea?

 

One year later, the patient went to her doctor, complaining of fever, pain in the left loin and burning micturition. Examination revealed marked tenderness in the left renal angle and a temperature of 39º C. Urine examination showed marked increase in both white and red cells.

 

11. What is the most probable diagnosis of this new event?

12. How to manage this new event?

 

The problem was managed successfully. Two years later the patient went to her doctor complaining of mild, persistent, dull pain in her right upper part of the abdomen, of 3 months duration. Abdominal ultrasonography revealed a bright liver and a thick walled gall bladder which contains multiple stones.

 

13. How to manage this new development?

 

One year later, the patient went to another doctor for follow up, because her doctor traveled to work in Saudi Arabia. The doctor stopped the patient’s previous medications and prescribed different oral tablets. The patient returned to the doctor after few days because she had repeated episodes of dizziness associated with palpitation and sweating since she took the new treatment. The doctor managed the situation and the patient did not have new episodes.

 

14. What were these episodes?

15. What was the type of the tablets prescribed for the patient?

 

Five years later the patient was admitted to the hospital to do an operation with general anaesthesia.

16. How to manage diabetes in this situation?

 

Three years later, the patient’s diabetes became poorly controlled by oral drugs and her doctor prescribed insulin injections, and diabetes was well controlled.

 

One year later the patient was admitted to the hospital in coma.

Examination revealed:

- Dry mouth and skin.

- Deep respiration.

- Pulse: 120/m, regular and weak.

- BP: 110/70.

- No signs of laterlization.

 

17. What are the causes of coma in a diabetic patient?

18. What is the most likely cause in this patient?

19. How to prove your diagnosis?

20. What are the diagnostic features of other causes of coma?

21. How to manage the patient?

 

During follow up of the patient, microalbuminuria was detected.

 

22. How microalbuminuria was detected?

23. How to control microalbuminuria?

24. What are the expected renal complications in the following years?

25. What are the expected neurological and eye manifestations at this point?


MCQs Part I

 

Case 1:

A 59-year-old woman had a left modified radical mastectomy for intraductal carcinoma          2 years previously.She presents with confusion, lethargy, and thigh pain. X-rays reveal a lytic lesion in the shaft of the femur.

 

1. Which of the following blood abnormalities is most likely?

(A) high glucose

(B) low calcium

(C) high potassium

(D) high calcium

(E) low magnesium

 

2. Which of the following is the most appropriate initial therapy?

(A) radiotherapy to the femur

(B) vigorous saline infusion

(C) tamoxifen

(D) chemotherapy

 

Case 2:

A 46-year-old attorney is noted to have normal cholesterol levels but a very high fasting triglyceride level of 1600. He is otherwise healthy and has no risk factors for CAD. Which of the following statements is correct?

 

(A) Hypertriglyceridemia is a strong independent risk factor for premature CAD.

(B) Dietary modification is usually sufficient.

(C) High triglyceride levels are associated with elevated high-densitylipoprotein(HDL) levels.

(D) Hypertriglyceridemia is usually associated with skin lesions.

(E) Control of triglyceride levels can prevent attacks of acute pancreatitis in patients with extreme hypertriglyceridemia.

 

Case3:

A 60-year-old patient with long-standing diabetes has a creatinine of  3.6, which has been stable for several years. Which of the following antibiotics requires the most dosage modification in chronic renal failure?

 

(A) tetracycline

(B) gentamicin

(C) erythromycin

(D) nafcillin

(E) chloramphenicol

 

Case 4:

A 25-year-old man was admitted to the intensive care unit with a severe head injury, with

fracture of the base of the skull. Approximately18 hours after the injury, he developed

polyuria. Urine osmolality was 150 mOsm/L and serum osmolality was 350 mOsm/L.           IV fluids were stopped, and 3 hours later, urine output and urine osmolality remained

unchanged. Five units of vasopressin were intravenously administered. Urine osmolality

increased to 300 mOsm/L. Which of the following is the most likely diagnosis?

 

(A) central diabetes insipidus

(B) nephrogenic diabetes insipidus

(C) water intoxication

(D) solute overload

(E) syndrome of inappropriate anti-diuretic hormone secretion (SIADH)

 

Case 5:

A70-year-old man with a 60 pack-year smoking history presents with cough and weight loss.He describes recent diffuse darkening of his skin and his CXR shows a mass suspicious for lung cancer in the left hilum. His laboratory tests reveal hypokalemia. Which of the following isthe most likely histology of his lung cancer?

 

(A) adenocarcinoma

(B) small cell

(C) squamous cell

(D) mesothelioma

(E) glioblastoma

 

Case 6:

A 75-year-old man who developed diabetes within the last 6 months was found to be jaundiced.He has remained asymptomatic, except for weight loss of about 10 lbs in 6 months. On physical examination, he is found to have a non-tender, globular, right upper quadrant mass that moves with respiration. A CT scan shows enlargement of the head of the pancreas, with no filling defects in the liver. What is the most likely cause of his painless jaundice?

 

(A) malignant biliary structure

(B) carcinoma of the head of the pancreas

(C) choledocholithiasis

(D) cirrhosis of the liver

(E) pancreatitis

 

Case 7:

A54-year-old woman with diabetes is noted tohave BP in the range of 140/90 mmHg on severaloccasions. Which of the following is thebest next step in management?

 

(A) initiate antihypertensive therapy

(B) advise weight loss and recheck BP in3 months

(C) advise regular exercise and recheck BPin 3 months

(D) no further intervention is necessary

(E) follow-up in 6 months for recheck of BP

 

Case 8:

A 42-year-old woman is noted to have amultinodular goiter on examination. She has

no symptoms and is clinically euthyroid.Which of the following statements about

Hashimoto’s thyroiditis is true?

 

(A) The condition is associated with prior radioactive exposure.

(B) Patients diagnosed with this disorder have an increased incidence of thyroid cancer.

(C) Corticosteroids are helpful in controlling the progression of the disease.

(D) Antinuclear antibodies are pathognomonic for this disease.

(E) Hashimoto’s thyroiditis is an autoimmune disease.

 

 

Case 9:

A 54-year-old alcoholic presents with complaints of tremors and muscle twitching. Physical examination reveals the presence of Trousseau's sign. Laboratory data show that serum magnesium is < 1 mEq/L (normal, 1.4 - 2.2 mEq/L). Which of the following findings would be most consistent with this information?

a) Decreased serum calcium

b) Decreased serum phosphate

c) Increased bone density

d) Increased plasma parathyroid hormone concentration

e) Increased urinary cAMP concentration

Case 10:

A 45 year old male with anorexia and weakness is found to have hypercalcemia. This is most likely to be secondary to abnormal

a) growth hormone

b) thyroid hormone

c) aldosterone

d) parathyroid hormone

e) leutenising hormone

Case 11:

A 34-year-old healthy woman develops sudden severe abdominal pain. On physical examination she is afebrile. The pain is centered in the mid-epigastric region, though there is marked diffuse tenderness in all quadrants. Bowel sounds are absent. No masses are palpable. Laboratory studies show her serum amylase is 410 U/L and lipase is 610 U/L. Which of the following laboratory test findings is most likely to be present in this woman?

A Hypercholesterolemia

B Positive urea breath test

C Hypercalcemia

D Elevated sweat chloride

E Positive serology for HBsAg

Case 12:

A 30-year-old woman, who has two healthy children, notes that she has had no menstrual periods for the past 6 months, but she is not pregnant and has been taking no medications. Within the past week, she has noted some milk production from her breasts. She has been bothered by headaches for the past 3 months. She suffered from problems in her vision  and visits an ophthalmolgiast, who finds her lateral vision to be reduced. On physical examination she is afebrile and normotensive. Which of the following laboratory test findings is most likely to be present in this woman?

A Increased serum cortisol

B Lack of growth hormone suppression

C Increased serum alkaline phosphatase

D Hyperprolactinemia

E Hyponatremia

Case 13:

A 28-year-old woman has had difficulty concentrating on her job at work for the past month. She is constantly getting up and walking around to visit co-workers. She complains that the work area is too hot. She seems nervous and spills her coffee a lot. She has been eating more but has lost 5 kg in the past month. On physical examination her temperature is 37.5 C, pulse 101/minute, respiratory rate 18/minute, and blood pressure 145/85 mm Hg. Which of the following laboratory findings is most likely to be present in this woman?

A Decreased plasma insulin

B Decreased TSH

C Decreased iodine uptake

D Increased ACTH

E Increased calcitonin

Case 14:

A 19-year-old previously healthy woman has had a mild pharyngitis followed by a high fever over the past 24 hours. When seen in the emergency room, her skin now shows extensive areas of purpura. Vital signs include T 39 C, P 102/minute, RR 21/minute, and BP 80/55 mm Hg. Laboratory studies show a serum sodium of 115 mmol/L, potassium 5.3 mmol/L, glucose 42 mg/dL, and creatinine 1.1 mg/dL. Which of the following is the most likely diagnosis?

A Idiopathic thrombocytopenic purpura.

B Disseminated tuberculosis

C Reactive systemic amyloidosis

D Sheehan syndrome

E Acute adrenal insufficiency

Case 15:

A 38-year-old man sees his physician because of abdominal pain, nausea, and constipation for the past 3 days. On physical examination he has no palpable abdominal masses and bowel sounds are present. His lungs are clear to auscultation. He has a heart rate of 80. An electrocardiogram demonstrates a shortened QT(corrected) interval and a prolonged PR interval. Upper GI endoscopy reveals multiple 1 cm diameter shallow ulcerations of the gastric antrum. Which of the following laboratory test findings is most likely to be present in this man?

A Thyroid peroxidase antibody of 4 IU/mL

B Serum calcium of 12.4 mg/dL

C Blood glucose of 225 mg/dL

D Total serum thyroxine of 21 ng/mL

E Plasma cortisol of 45 microgm/dL at 8 am

Case 16:

A 29-year-old primigravida who received no prenatal care has marked vaginal bleeding after the onset of labor at 38 weeks gestation. Cesarean section is performed and a lacerated low-lying placenta is removed. She remains hypotensive for 6 hours and requires transfusion of 12 packed RBC units. Postpartum, she becomes unable to breast-feed the infant. She does not have a resumption of normal menstrual cycles. She becomes more sluggish and tired. Laboratory findings include hyponatremia, hyperkalemia, and hypoglycemia. Which of the following pathologic lesions is she most likely to have had following delivery?

A Bilateral adrenal hemorrhage

B Pituitary necrosis

C Subacute thyroiditis

D Metastatic choriocarcinoma

E Insulitis

Case 17:

A 58-year-old man with a history of diabetes mellitus has noted the presence of bone pain, especially of his hands, for the past 6 months. On physical examination there is no swelling or redness of his hands, no joint deformity, but the range of motion is slightly decreased. Laboratory studies show sodium 139 mmol/L, potassium 4.0 mmol/L, chloride 98 mmol/L, C02 22 mmol/L, glucose 153 mg/dL, creatinine 7.8 mg/dL, calcium 7.8 mg/dL, phosphorus 5.7 mg/dL, total protein 6.2 g/dL, and albumin 4.0 g/dL. Which of the following conditions is this man most likely to have?

A Adrenal adenoma

B Medullary thyroid carcinoma

C Extra-adrenal pheochromocytoma

D  secondary hyperparathyroidism

E Pituitary adenoma

Case 18:

A 49-year-old woman has had increasing cold intolerance, weight gain of 4 kg, and sluggishness over the past two years. A physical examination reveals dry, coarse skin and alopecia of the scalp. Her thyroid is not palpably enlarged. Her serum TSH is 11.7 mU/L with thyroxine of 2.1 micrograms/dL. A year ago, anti-thyroglobulin and anti-microsomal autoantibodies were detected at high titer. Which of the following thyroid diseases is she most likely to have?

A DeQuervain disease

B Papillary carcinoma

C Hashimoto thyroiditis

D Nodular goiter

E Graves disease

Case 19:

A 48-year-old woman has experienced constant back pain exacerbated by movement over the past month. She reports increasing weakness over the past 3 months. On physical examination her blood pressure of 165/110 mm Hg. She is mildly obese with a BMI of 28. A radiograph of the spine reveals a compressed fracture at T10. Laboratory findings include a serum glucose of 155 mg/dL. Which of the following pathologic lesions is most likely to explain her findings?

A Adrenal cortical carcinoma

B Anaplastic thyroid carcinoma

C Empty sella syndrome

D Pheochromocytoma

E Multinodular goiter

Case 20:

A 33-year-old woman has noted a weight gain of 6 kg over the past year. She has normal menstrual periods. On physical examination her blood pressure is 170/105 mm Hg. A serum electrolyte panel shows sodium 141 mmol/L, potassium 4.4 mmol/L,  glucose 181 mg/dL, and creatinine 1.0 mg/dL. Which of the following radiologic findings would you most expect to be present in this patient?

A 2 cm right adrenal mass with abdominal CT scan

B 4 cm mass at aortic bifurcation with MR imaging

C Multiple pulmonary nodules on chest radiograph

D 10 cm cystic right ovarian lesion by abdominal ultrasound

E 2 cm "hot" thyroid nodule with Tc99 scintigraphic scan

Case 21:

An 35-year-old woman has had insomnia for the past 4 months. She has also had episodes of diarrhea with up to 4 loose stools per day. On physical examination, she exhibits bilateral proptosis. Her outstretched hands demonstrate a fine tremor. On palpation of her neck, the thyroid gland does not appear to be enlarged and no masses are palpable. Laboratory studies show a serum TSH of 0.8 microU/mL in association with a serum free thyroxine of 5.1 ng/dL. Which of the following is the most likely diagnosis?

A Graves disease

B Pituitary adenoma

C Chronic thyroiditis

D Prior thyroidectomy

E Nodular goiter

Case 22:

Top of Form

A 25-year-old woman has had a 10 kg weight loss over the past 6 months, despite the fact that she is not dieting or trying to lose weight. On physical examination she appears anxious and worried. Her hands are warm and tremulous. Vital signs show her temperature to be 37.4 C, pulse 105/minute, respirations 23/minute, and blood pressure 135/75 mm Hg. Serum electrolytes include sodium 141 mmol/L, potassium 4.2 mmol/L, glucose 78 mg/dL, and creatinine 0.8 mg/dL. Which of the following laboratory test findings is most likely to be present in this woman?

A Plasma cortisol of 40 microgm/dL at 8 am

B Serum antinuclear antibody of 1:256

C Urinary free catecholamines of 500 microgm/24 hr

D Serum gastrin of 200 pg/mL

E Serum total thyroxine of 14 microgm/dL

Case 23:

A 50-year-old man has experienced episodic headaches for the past 3 months. On physical examination his blood pressure is 185/110 mm Hg, with no other remarkable findings. Laboratory studies show sodium 145 mmol/L, potassium 4.3 mmol/L, chloride 103 mmol/L, C02 26 mmol/L, glucose 91 mg/dL, and creatinine 1.3 mg/dL. An abdominal CT scan shows a 7 cm left adrenal mass. During surgery, as the surgeon is removing the left adrenal gland, the anesthesiologist notes a marked rise in blood pressure. Which of the following laboratory test findings would have been most likely have been present in this patient prior to surgery?

A Decreased serum cortisol

B Decreased urinary homovanillic acid

C Increased serum ACTH

D Increased urinary free catecholamines

E Elevated serum ANCA

Case 24:

A 47-year-old woman feels a "lump" in her neck that she didn't notice 5 months before. Her physician palpates a firm nodule about 2 cm in size to the left of midline in the region of the thyroid gland. By scintigraphic scanning with Tc99, this nodule appears "cold" with normal activity in the surrounding thyroid gland. Which of the following is the most likely diagnosis?

A Papillary carcinoma

B Follicular adenoma

C Thyroglossal duct cyst

D Toxic nodular goiter

E Granulomatous thyroiditis

Case 25:

A 49-year-old woman has had multiple episodes of lower abdominal pain for the past year. On 3 occasions she passed a urinary tract stone during or following an episode of pain. During the past month she has experienced pain in her right middle finger. On physical examination there is pain on palpation of her right 3rd proximal phalanx. Laboratory studies show a serum calcium of 13.7 mg/dL, phosphorus of 1.9 mg/dL, creatinine 1.4 mg/dL, and albumin 4.8 g/dL. Which of the following bone lesions is she most likely to have?

A Osteitis fibrosa cystica

B Osteoid osteoma

C Osteochondroma

D Osteomyelitis

E Osteoporosis

Case 26:

A 40-year-old truck driver has had difficulty using his side mirrors for traffic behind him. He has never had any major medical problems in the past. He visits an optometrist, who determines that he has bilateral lateral visual field deficits, but his vision is 20/20. A head CT scan reveals slight enlargement of the sella turcica. Which of the following hormones is most likely being secreted in excessive amounts in this man?

A Antidiuretic hormone

B Prolactin

C ACTH

D Growth hormone

E Luteinizing hormone

Case 27:

A 45-year-old man has had headaches for 4 months. On physical examination he is found to have a blood pressure of 170/110 mm Hg. Laboratory studies show a serum sodium of 146 mmol/L, potassium 2.3 mmol/L glucose 82 mg/dL, and creatinine 1.2 mg/dL. His plasma renin activity is 0.1 ng/mL/hr. Which of the following abnormalities is the most likely cause for these findings?

A 21-hydroxylase enzyme deficiency

B Adrenal adenoma

C Pituitary adenoma

D Exogenous corticosteroid administration

E Renal cell carcinoma

Case 28:

A 40-year-old woman has noted painless swelling of her neck for the past 3 weeks. On physical examination there is diffuse enlargement of her thyroid. Laboratory studies show an increased titer of anti-thyroid peroxidase and anti-thyroglobulin antibodies. Within a month, the swelling has diminished. Which of the following complications is she most likely to develop?

A Amyloidosis

B Hypothyroidism

C Non-Hodgkin lymphoma

D Papillary carcinoma

E Riedel thyroiditis

Case 29:

A 45-year-old woman with severe rheumatoid arthritis has been on chronic corticosteroid therapy for the past 15 years. She is admitted for an orthopedic procedure to correct joint deformity from her disease. She continues to receive her regular dosage of 5 mg of prednisone per day. Three days postoperatively, she develops an aspiration pneumonia with Klebsiella pneumoniae cultured from sputum. Five days following the surgery, she becomes drowsy. Laboratory findings at that time include: sodium 105 mmol/L, potassium 5.4 mmol/L, glucose 40 mg/dL, and creatinine 1.1 mg/dL. Which of the following complications is most likely to have occurred in this patient?

A Anterior pituitary necrosis

B Waterhouse-Friderichsen syndrome

C Acute Addisonian crisis

D Conn syndrome

E 21-hydroxylase deficiency

Case 30:

A 38-year-old woman has had a feeling of fullness in her neck for the past year. She is otherwise asymptomatic. Her physician palpates a symmetrically enlarged thyroid gland. It is not painful to palpation. She has no difficulty swallowing. There is no palpable lymphadenopathy. She is afebrile. Her serum TSH is 3.5 mU/L with thyroxine of 8.2 micrograms/dL. Thyroid peroxidase antibody is not detected. Two years later, her thyroid has not appreciably changed in size. Which of the following conditions is she most likely to have?

A Graves disease

B Nodular goiter

C Hashimoto thyroiditis

D Anaplastic carcinoma

E Follicular adenoma

Case 31:

A 48-year-old man noted an increase in weight over the past 6 months, along with bruises on his skin with even minor trauma and back pain. On physical examination he has obesity in a truncal distribution. He has a blood pressure of 160/110 mm Hg. A radiograph of the spine reveals a compressed fracture of T11. Which of the following neoplasms is he most likely to have?

A Pheochromocytoma of bladder

B Follicular carcinoma of thyroid

C Osteosarcoma of femur

D Small cell anaplastic carcinoma of lung

E Islet cell carcinoma of pancreas

Case 32:

A 41-year-old man has been drinking large quantities of water--up to 20 liters per day--for the past week. On physical examination there are no abnormal findings except for diminished skin turgor and dry mucous membranes. Laboratory studies show sodium 162 mmol/L, potassium 4.1 mmol/L, His serum glucose is 75 mg/dL and creatinine 1.2 mg/dL. His serum osmolality is high ( 343 mOsm/kg). A deficiency of which of the following hormones is most likely present in this man?

A Antidiuretic hormone

B Oxytocin

C Insulin

D Growth hormone

E Prolactin

Case 33:

A 50-year-old man has been diagnosed with a follicular neoplasm of the thyroid. He undergoes a total thyroidectomy. Within a day following surgery, he is noted to have tingling sensations and neuromuscular irritability. Which of the following serum laboratory tests should be ordered immediately to determine further therapy for this man?

A TSH

B Parathormone

C Total thyroxine

D Ionized calcium

E Calcitonin

Case 34:

A 57-year-old man is found comatose. On physical examination he has decreased skin turgor. Laboratory studies show a blood glucose of 780 mg/dl. Urinalysis reveals no ketosis or proteinuria, though there is 4+ glucosuria. Which of the following is the most likely diagnosis?

A Islet cell tumor secreting glucagon

B Type I diabetes mellitus

C Cushing syndrome

D Ingestion of a large quantity of sugar

E Type II diabetes mellitus

Case 35:

A clinical study is performed involving subjects who developed Addision disease. They were recorded to have laboratory studies with hyponatremia, hyperkalemia, hypoglycemia, and decreased plasma cortisol. They became hypotensive. In some subjects, this disease had an acute onset over less than 2 days' time. Which of the following diseases is most likely to produce this acute course?

A Waterhouse-Friderichsen syndrome

B Metastatic small cell anaplastic carcinoma

C Disseminated Mycobacterium tuberculosis

D Reactive systemic amyloidosis

E Blunt force abdominal trauma

Case 36:

A 17-year-old girl with  chronic renal failure and was placed on chronic hemodialysis. She developed severe hypertension. However, she had difficulty accepting the reality of her disease, and she missed dialysis appointments and did not take her antihypertensive medication regularly. Laboratory studies now show her serum ionized calcium is 3.9 mg/dl with phosphorus 6.2 mg/dl and albumin 3.6 g/dl. Which of the following bone lesions is she most likely to have?

A Osteitis fibrosa cystica

B Fibrous dysplasia

C Osteosarcoma

D Giant cell tumor

E Osteopetrosis

Case 37:

A 49-year-old woman has had increasing malaise for the past 6 months. On physical examination there are no abnormal findings except for diminished sensation to pinprick and light touch in her lower legs and feet. She is afebrile and normotensive. Laboratory studies show serum creatinine 4.5 mg/dL, urea nitrogen 42 mg/dL, glucose 130 mg/dL, and hemoglobin A1C 7.9%. A urinalysis shows 1+ glucose, 1+ protein, no blood, and no ketones. Urine microscopic examination shows 1 RBC/hpf and 1 WBC/hpf. Which of the following pathologic abnormalities is she most likely to have in her kidneys?

A Acute pyelonephritis

B Acute tubular necrosis

C Chronic glomerulonephritis

D Hydronephrosis

E Nodular glomerulosclerosis

Case 38:

Top of Form

A 70-year-old male was receiving amiodarone 200 mg daily for intermittent atrial fibrillation. However; he. was aware of tiredness and lethargy. He appeared clinically euthyroid with no palpable goitre. Investigations revealed:

Serum tree T4                           23pmol/L (9-26)

Serum total T3                         0.8 nmol/L (0.9-2.8)

Serum TSH                              8.2 mU/L (<5)

Which of the following statements would explain these results?

A-     Abnormal thyroxine binding globulin      

B-   Amiodarone-induced hypothyroidism                                                                                       

C-   sick euthyroid syndrome

D-  Spontaneous hypothyroidism

E-      TSH secreting pituitary adenoma

Case 39:

A middle aged woman presents with new onset palpitations. She also commented that she had lost weight recently despite an increased appetite. Examination reveals a goitre and a degree of exophthalmos. During physical examination, she fell unconscious. Blood pressure was 70/40 mmHg. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. What is the appropriate immediate management?

A-     Anticoagulation

B-   Carbimazole

C-   DC cardioversion

D-  Intravenous amiodarone

E-   Lugol Iodine

Case 40:

A 17-year-old girl is admitted with a 2 day history of rigors due to a urinary tract infection. On examination she appears unwell, has a Body Mass Index of 31kg/m2, a temperature of 39°C; examination is otherwise normal.

Initial biochemistry revealed:

4 mmol/L (3.5-4.9)

 

Potassium

7 mmol/L (2.5-7.5)

Urea

33 mmol/L (3.0-6.0)

Glucose

7.3 (7.36-7.44)

pH

14 mmol/L (20-28)

 

Standard bicarbonate

-10 mmol/L

Base deficit

 

 

·        urinalysis negative for ketones

Which one of the following is the best initial treatment for her hyperglycaemia?

A-     Metformin

B-     Metformin plus Gliclazide

C-   Rosiglitazone

D-  Sliding scale IV insulin infusion                                  

E-   Subcutaneous insulin mixture

 

Case 41:

A 40-year-old obese man with a BMI of 36 kg/m2 was diagnosed with type 2 diabetes mellitus 1-year ago. He was now eating a healthy diet and was getting sufficient exercise. He did not report any osmotic symptoms and so far had been free from any micro- or macrovascular complications. He was currently not taking any medications.

Investigations at his annual diabetic follow-up were as follows:

(3.8-6.4)

7.4%

Haemoglobin A,C

(3.0-6.0)

9.8 mmol/l   

Fasting plasma glucose

(137-144)

138 mmol/l   

Serum sodium

(3.5-4.9)

4.7mmol/l   

Serum potassium

(2.5-7.5)

4.3 mmol/l   

Serum urea

(60-110)

88µmol/l    

Serum creatinine

 

What would be the most appropriate management to optimise his glycaemic control?

A-     Continue with lifestyle measures

B-   Gliclazide therapy

C-   Metformin therapy                                        

D-  Orlistat therapy

E-   Rosiglitazone therapy

 

Case 42:

A 59-year-old woman has had insulin dependent diabetes mellitus for over two decades. The degree of.control of her disease is characterized by the laboratory finding of a HbAlc of 10.1% (3.8-6.4%). She complains of repeated episodes of abdominal pain following meals. These.episodes have-become more frequent and last for longer periods over the last couple of months.

On physical examination, there are no abdominal masses or organomegaly and no tenderness to palpation.

Which of the following findings is most likely to be present?

A-  Acute pancreatitis

B-   Chronic renal failure

C-   Hepatic infarction

D-  Mesenteric artery occlusion                              

E-   Ruptured aortic aneurysm

Case 43:

A 45-year-old female, attends the diabetic annual review clinic. Her body mass index has increased over the year to 33.3. How do you calculate body mass index?

A-     Height/Weight

B-   Height/(Weight)2

C-   Weight/Height

D-  Weight/(height)2                                    

E-   Weight/Height

Case 44:

A 38-year-old lady was diagnosed with gestational diabetes at 28 weeks of pregnancy. She had a BMI of 38 and denied any osmotic symptoms. Her fetal ultrasound at 24 weeks gestation reported normal fetal growth. She has been complying with a healthy diet and her capillary blood glucose monitoring had revealed readings usually between 8 to 12 mmol/L (3.0-6.0). Her. recent .HbAlc measured 6.8% (3.8-6.4).

What is the, next most appropriate management step?

A-     Gliclazide therapy

B-   Insulin therapy                                               

C-   Metformin therapy

D-  Repeat HbAlc in a fortnight

E-   Rosiglitazone therapy

 

Case 45:

A 35-year-old woman is noted to have ++ glycosuria by her GP. Her BMI is 35 kg/m2 and a fasting plasma glucose is 7.4 mmol/1 (3.0-6.0).

Which one of the following measures would be most effective in reducing her insulin resistance?

 

A-     Glibenclamide

B-   Insulin

C-   Metformin

D-  Weightless                                             

E-   Repaglinide

 

Case 46:

A 60-year-old male who was previously fit and well presented with a six week history of blurring of vision. His investigation revealed a fasting plasma glucose of 12.9 mmol/L (3.0 6.0). What is the most likely cause of his blurred vision?

A-     Cataract

B-   Maculopathy

C-   Osmotic changes in the lens                                 

D-  Proliferative diabetic retinopathy

E-   Retinal vein thrombosis

 

Case 47:

A 26-year-old male with a three year history of type 1 diabetes presents with fever, vomiting and is dehydrated. Investigations revealed:-

 

148 mmol/L (137-144)

Sodium

3.3 mmol/L (3.5-4.9)

Potassium

24 mmol/L (2.5-7.5)

Urea

33 mmol/L (3.0-6.0)

Glucose

7.18(7.36-7.44) 

Blood pH

 

 

What would be the typical total body water deficit associated with his diabetic ketoacidosis?

A-              1 litre

B-   3 litres

C-   6 litres                                                              

D-  8 litres

E-   10 litres

 

Case 48:

A diagnosis of diabetes mellitus is being considered in 32-year-old woman who is 16 weeks pregnant. Her body mass index (BMI) was 22 kg/m2 (18-25). A 75g oral glucose tolerance test was reported as follows

Normal range

Plasma glucose concentration

Time

3.0-6.0

6.0mmol/l

0 hr

<11.1

12.5 mmol/l

2hr

 

 

Which of the following is the most appropriate next step in the management of this patient?

A-              Glipizide therapy

B-   Insulin therapy                                       

C-   Low calorie diet

D-  Metformin therapy

E-   Repeat OGTT in four weeks

 

Case 49:

A 42-year-old male presents with polyuria and polydipsia. He is a non-smoker and drinks approximately 12 units per week. He is employed as a taxi driver. On examination he has a BMI of 33.4 kg/m2, a blood pressure of 132/82 mmHg with all other aspects of the cardiovascular examination normal. Investigations confirm a diagnosis of diabetes mellitus with a fasting blood glucose concentration of 12.1 mmol/L (3-6). His HbAlc is 9% (3.8-6.4) and total cholesterol is 5.8 mmol/L (<5.2). What is the most appropriate initial treatment for this patient?

 

A-  Diet and lifestyle advice                                       

B-   Gliclazide

C-   Metformin

D-  Oriistat

E-   Simvastatin                           


Answers

 

Case 1:

Answer: 1: (D), 2: (B)

Hypercalcemia is common in patients with malignancy. The most common tumors that cause hypercalcemia are breast cancer, multiple myeloma, lymphoma, and squamous cell cancers.

There are several mechanisms by which hypercalcemia can occur:

  • Osteolytic metastases with local release of cytokines; leading to increased bone resorption and release of calcium from bone.
  • Tumor secretion of parathyroid hormone;  leading to increased bone resorption and distal renal tubular calcium reabsorption
  • Tumor production of vitamin D; leading to increased bone resorption and intestinal calcium absorption.
  • Immobilization; leading to bone resorption.

Hypercalcemia is often manifested by confusion and lethargy. The other metabolic abnormalities usually are not associated with confusion.

Therapy is directed at increasing renal calcium clearance and inhibiting further bone resorption. Saline infusion raises the glomerular filtration rate and decreases calcium reabsorption in the proximal tubule. Under life-threatening circumstances, the infusion may need to be aggressive, as much as 6 L of saline daily plus furosemide.

Radiotherapy will do nothing for the calcium. Tamoxifen is an anti-estrogen used in the treatment of breast carcinoma and other malignancies. When used in the presence of bone metastases, it may contribute to hypercalcemia. Chemotherapy will not decrease the calcium levels. Glucocorticoids have an antitumor effect and reduce tumor production of humoral mediators, but act slowly.

 

Case 2:

Answer:  (E)

Hypertriglyceridemia has not been shown to be a strong independent risk factor for CAD, however, epidemiologic data do suggest a relationship. According to the National Cholesterol Education Program, when tirglycerides are above 200 mg/dL then non-HDL (total HDL) cholesterol becomes a pharmacologic treatment target. Severely elevated triglycerides (1000 mg/dL) are a recognized risk factor for attacks of acute pancreatitis, and control of the triglycerides can prevent these attacks. Diet alone is usually not sufficient at these high levels. A National Institutes of Health Consensus Conference has recommended that treatment be initiated in all patients with triglycerides greater than 500 mg/100 mL to prevent acute pancreatitis. Skin lesions are not present with hypertriglyceridemia.

Case3:

Answer:  (B)

Many drugs require dosage modifications in chronic renal insufficiency. Bioavailability, distribution, action, and elimination of drugs all may be altered. Drugs that are nephrotoxic may be contraindicated or used only with extreme care in renal insufficiency. The aminoglycosides, vancomycin, ampicillin, most cephalosporins, methicillin, penicillin G, sulfonamides, and trimethoprim all should be given in reduced dosage to patients with chronic renal failure.

Aminoglycosides & vancomycin can be nephrotoxic and should be used with caution in renal insufficiency.

The small group of antibiotics not needing dosage modification includes chloramphenicol, erythromycin, the isoxazolyl penicillins (nafcillin and oxacillin), and moxifloxacin.

 

Case 4:

Answer:  (A)

Diabetes insipidus, a deficiency of pituitary anti-diuretic hormone (ADH) (arginine vasopressin), causes water loss because of failure to facilitate reabsorption of water in the distal tubules and collecting ducts of the kidneys. In central diabetes insipidus, there is impaired production of vasopressin, and in nephrogenic diabetes insipidus, the distal renal tubules are refractory to vasopressin. In central diabetes insipidus, urine osmolality remains unchanged. If water intoxication were present, stopping IVfluids should have increased urine osmolality. With solute overload, serum osmolality would have been higher. In SIADH, urine osmolality is usually higher than serum osmolality.

Case 5:

Answer:   (B)

Endocrine syndromes are seen in 12% of patients with lung cancer.

Squamous cell carcinoma is associated with PTH-related peptide.

ACTH and ADH secretion can be associated with small cell lung carcinoma.

ACTH-secreting tumors are associated with darkening of the skin and Hypokalemia.

Case 6:

Answer; (B)

Adenocarcinoma of the pancreas arises from ductal epithelium. Because of fibrous tissue formation, the terminal bile duct occludes, causing jaundice. Typically, in the early stages, the patient is free of pain. With invasion of retroperitoneal structures, the patient may sometimes have severe and constant pain. Often, patients have a history of weight loss and present with unexplained diabetes. Because of gradual obstruction, the gall bladder distends, unless it has lost its distensibility because of previous scarring.

Malignant biliary stricture, choledocholithiasis, and cirrhosis of the liver are ruled out by the appearance of the CT. Pancreatitis is rarely associated with jaundice and would be painful.

Case 7:

Answer:  (A)

The Hypertension Optimal Treatment Study and the U.K. Prospective Diabetes Study both showed benefit in targeting BP to the normal range in patients with diabetes(i.e., 130/85 mmHg). This patient has multiple readings of 140/90 mmHg and should be treated with antihypertensive medication.

Case 8:

Answer: (E)

Hashimoto’s thyroiditis, an autoimmune condition, is the leading cause of multinodular goiter in the United States.

Although not unique to this condition, anti-microsomal antibodies are found in 70–95% of patients. Anti-nuclear antibodies are associated with SLE. Although an autoimmune process, steroids are of no benefit in this condition.

One-third of patients experience progressive loss of glandular function, and eventually become hypothyroid.

There is no increased incidence of thyroid cancer.


Case 9:

(A) correct.

  • Hypomagnesemia causes generalized weakness, anorexia, and positive Trousseau & Chvostek signs. Apathy, delirium, coma and convulsions, may occur.
  • Hypomagnesemia may be associated with ventricular arrhythmias.
  • Hypokalemia occurs in 40-60 % of hypomagnesemic patients, due to underlying disorders that cause both magnesium & potassium loss, as diuretics &diarrhea, or due to renal potassium wasting that is caused by hypomagnesemia.
  • Hypocalcemia is a sign of severe hypomagnesemia (<1.0 meq/L).     It is due to inhibition of PTH secretion and bone resistance to PTH.

Case 10:

CORRECT: (D)

Bottom of Form

Primary hyperparathyroidism is resulting from over activity of one or more parathyroid glands. It is caused usually by an adenoma, less commonly by primary hyperplasia.

It causes hypercalcemia, hypophosphatemia & hypercalciuria. Calcium stones in the urinary tract are frequently present. Symptoms in primary hyperparathyroidism such as fatigability, anorexia and weakness result from the hypercalcemia. Serum parathyroid hormone level can be determined accurately by radioimmunoassay or immunoradiometric assay.

Case 11:

(C) CORRECT.

Hypercalcemia is a less common cause for acute pancreatitis that can be found in persons with hyperparathyroidism. Once the pancreatitis has started, the formation of the chalky soap deposits of fat necrosis may draw off calcium to produce hypocalcemia.


Case 12:

(D) CORRECT.

The most common mass lesion of the pituitary in the adult is an adenoma that secretes prolactin, and this explains the amenorrhea-galactorrhea that she has been experiencing. A large sellar mass can compress the optic chiasm to produce bitemporal hemianopsia.

 

Case 13:

(B) CORRECT.

There are both thyroid-stimulating immunoglobulins (TSI) and thyroid growth-stimulating immunoglobulins (TGI) in Graves disease that produce hyperthyroidism. The amount of thyroid hormone production goes up, suppressing TSH secretion from the pituitary.

Case 14:

(E) CORRECT.

This is acute adrenal insufficiency marked by hyponatremia, hyperkalemia, and hypoglycemia ( the Waterhouse-Friderischsen syndrome).

Case 15:

(B) CORRECT.

He most likely has a parathyroid adenoma secreting excessive PTH to increase serum calcium and decrease serum phosphorus. The hypercalcemia leads to increased gastrin production and peptic ulcer disease. Hypercalcemia produces cardiac arrhythmias (or asystole).

Case 16:

(B) CORRECT.

She has Sheehan syndrome from post-partum anterior pituitary necrosis, leading to loss of pituitary hormones, including gonadotrophic hormone deficiency. The pituitary enlarges in pregnancy, which makes its blood supply more tenuous, and the pituitary is more susceptible to necrosis from events that lead to hypotension.


Case 17:

(D) CORRECT.

He has secondary hyperparathyroidism from chronic renal failure. Renal failure with retention of phosphorus drives the calcium down and PTH secretion up, leading to osteitis fibrosa cystica and bone pain.

 

Case 18:

(C) CORRECT.

Hashimoto thyroiditis is the most common cause for hypothyroidism in adults. Though the thyroid may initially have been painlessly enlarged, over time the inflammation leads to atrophy of the thyroid with hypothyroidism. Anti-thyroid autoantibodies are helpful in establishing the diagnosis.

 

Case 19:

(A) CORRECT.

She has Cushing syndrome with osteoporosis, hypertension, obesity, and diabetes mellitus. Many adrenal cortical carcinomas function and can produce excess cortisol.

Case 20:

(A) CORRECT.

She has an adrenal cortical adenoma producing excess corticosteroids and leading to Cushing syndrome.

Case 21:

(A) Correct.

In Graves disease, there is increased amount of thyroid hormone produced, leading to signs and symptoms of hyperthyroidism. The TSH is low.

Case 22:

Top of Form

(E) CORRECT.

She is manifesting the signs and symptoms of hyperthyroidism and probably has Graves disease.


Case 23:

(D) CORRECT.

The history is most consistent with a pheochromocytoma of the adrenal medulla (about 10% of pheochromocytomas can be extra-adrenal), which can episodically secrete large amounts of catecholamines. When the surgeon manipulated the mass, catecholamines were released.

Case 24:

(B) CORRECT.

The majority of 'cold' thyroid nodules are benign and many are adenomas.

Case 25:

(A) CORRECT.

Osteitis fibrosa cystica is a metabolic bone disease that occurs as a complication (one of the causes for bone pain) of primary hyperparathyroidism, which she likely has because her serum calcium is elevated and phosphorus decreased.

Case 26:

(B) CORRECT.

More pituitary adenomas secrete prolactin than any other hormone. Also, he did not have symptoms indicative of any other hormonal secretion. In a man, prolactinemia may not have major effects. The adenoma pressing on the optic chiasm is a mass effect that did explain his visual problem.

Case 27:

(B) CORRECT.

The history points to an aldosterone secreting neoplasm, which is usually a small adenoma within adrenal cortex. This is known as Conn syndrome, one of the surgically treatable causes for hypertension.


Case 28:

(B) CORRECT.

Hypothyroidism can occur years later in the course of Hashimoto thyroiditis. This is the most common cause for hypothyroidism in adults.

Case 29:

(C) CORRECT.

The hyponatremia, hyperkalemia, and hypoglycemia are characteristic for acute adrenal failure. She received a normal replacement dose of corticosteroids during her hospitalization, but the stress of surgery and infection increased her need for cortisol. Her chronic corticosteroid therapy resulted in adrenal atrophy, and her own adrenals could not respond to the challenge.

Case 30:

(B) CORRECT.

The most common cause for thyroid enlargement is a simple, nodular goiter. Most patients are euthyroid with this condition. Places far away from a seacoast (a source for iodine) are where endemic goiter used to be seen. Use of iodized salt eliminated the problem.

Case 31:

(D) CORRECT.

Small cell ('oat cell') carcinomas can secrete a variety of hormone-like substances that produce many types of paraneoplastic syndromes, of which Cushing syndrome from ectopic ACTH secretion is one.

 

Case 32:

(A) CORRECT.

He has 'central' diabetes insipidus. ADH is made in the hypothalamus and then stored and released from the posterior pituitary. A lack of ADH leads to polydipsia and polyuria from excessive excretion of free water by the kidney, leading to hypernatremia and increased serum osmolality.


Case 33:

(D) CORRECT.

The parathyroids can be inadvertently removed or traumatized with thyroid surgery, resulting in post-operative hypocalcemia. Post-surgical monitoring of calcium levels is routinely performed following thyroidectomy.

Case 34:

(E) CORRECT.

The complication of diabetes mellitus known as hyperosmolar coma is most typical for type II diabetes mellitus; most affected persons are overweight and have increased insulin resistance, not an absolute lack of insulin secretion. Thus, there is no ketoacidosis accompanying the hyperglycemia in hyperosmolar coma.

Case 35:

(A) CORRECT.

Meningococcemia is the usual cause for the Waterhouse-Friderichsen syndrome, with extensive adrenal hemorrhages and adrenal failure developing rapidly. Organisms other than Neisseria meningitidis are less commonly implicated.

Case 36:

(A) CORRECT.

Osteitis fibrosa cystica can be seen with secondary hyperparathyroidism as a consequence of chronic renal failure, though it is more often a complication of primary hyperparathyroidism.

Case 37:

(E) CORRECT.

The classic lesion with diabetes mellitus is nodular glomerulosclerosis, which gradually reduces renal function. Diffuse glomerulosclerosis may also be present.

Case 38:

Top of Form

B is correct.

The results show normal T4, low T3 with elevated TSH. These results are typical of amiodarone induced hypothyroidism which inhibits the peripheral conversion of T4 to T3.

Case 39:

C is correct.

The patient is haemodynamically compromised due to AF. The emergency management is DC cardioversion Adverse signs necessitating DC cardioversion are BP ≤ 90mmHg, chest pain, heart failure, impaired consciousness and heart rate > 200bpm.

Case 40:

D is correct.

This patient has a metabolic acidosis with pH of 7.3 and low bicarbonate likely due to sepsis. She is likely to be a type 2 diabetic, given the BMI, with uncontrolled hyperglycemia but is unlikely to have classical diabetic ketoacidosis because the urine is negative for ketones.

It is important that her glycemia is controlled to promote recovery from the sepsis. This is best achieved with intravenous insulin initially.

Case 41:

C is correct.

This obese male has sub-optimal control of his hyperglycemia (HbAlc 7.4%) despite diet. One should aim for a HbAlc below 7% and so the addition of metformin would be the most appropriate choice for this man.

Case 42:

D is correct.

Diabetes- especially Type 2 diabetes- is associated with macrovascular disease. Smoking is a further risk factor for macrovascular atherosclerosis. After a meal splanchnic blood flow is increased. If the mesenteric artery is occluded the lack of blood flow to the bowel will produce ischemic type pain.


Case 43:

D is correct.

BMI is one of the most important calculations of anthropometry, is calculated as weight in Kg over (height in meters) squared and measured in kg/m2. BMI can be defined as underweight (less than 18.5), normal (18.5-24.9), overweight (25-29.9) and obese. A BMI above 30 diagnoses obesity and has prognostic value indicating increased propensity to develop diabetes, cancer, osteo arthritis and depression.

Case 44:

B is correct.

This patient with gestational diabetes has capillary glucose concentrations that are excessive (>7) and therefore the most appropriate therapy would be insulin.

Case 45:

D is correct.

The most appropriate treatment of this obese type 2 diabetic female which would also substantially reduce insulin concentrations is weight loss. Glibenclamide may be associated with increased insulin resistance as it stimulates insulin secretion, as does repaglinide. Metformin would improve insulin sensitivity but would not do it as much as weight loss. The unfortunate thing is that weight loss is the most difficult strategy for the patient to adhere to.

Case 46:

C is correct.

This patient is a newly diagnosed diabetic as we are told he was previously fit and well. Therefore the most probable explanation for his blurred vision is osmotic changes.


Case 47:

C is correct.

The typical fluid- deficit associated with DKA is approximately 6 liters. The initial half of this amount is derived-from intracellular fluid and precedes signs of dehydration, while the other half is from extracellular fluid and is responsible for clinical signs of dehydration., Appropriate fluid replacement requires 1 liter of Normal saline over the first 1/2 hour, then 1 liter over the next hour, then 1 liter over the next two hours followed by 1 liter every 4 hours depending on the degree of dehydration.

Case 48:

B is correct.

The result confirms a diagnosis of gestational diabetes mellitus with the 2hr OGTT result above 11.1 mmol/1. To minimise the fetal consequences of GDM (macrosomia, fetal malformations, still birth, IUGR etc), the patient's glycaemia should be strictly controlled with insulin. A low calorie diet is inappropriate and neither metformin nor glipizide are licensed for use in pregnancy. There is no point in repeating the OGTT in 4 weeks as control is required NOW.

Case 49:

A is correct.

This patient who has typical type 2 diabetes, which should initially be treated with diet and lifestyle advice - appropriate dietary advice and exercise programme to endeavour to achievce weight loss. He should receive at least three months of this intervention before re­assessing and considering pharmacological intervention if the lifestyle approaches are not succeeding. If this is the case then the drug of choice would be metformin.


MCQs Part II

 

1) Features of hypoglycemia do not include

A.   Drenching sweat

B.   Tachycardia

C.   Tachypnoea

D.   Brisk jerk

E.    Paraesthesias

 

2) Earliest changes observed by ophthalmoscope in background retinopathy of diabetes is

A.   Venous dilatation

B.   Microaneurysms

C.   Increased capillary permeability

D.   Arterio-venous shunts

E.    Exudates

 

3) Which is not a part of metabolic 'syndrome x':

A.   Hyperlipidaemia

B.   Obesity

C.   Ischaemic heart disease

D.   Hypertension

E.    Insulin resistance

 

4) All are features of diabetic ketoacidosis except:

A.   Hyperthermia

B.   Drowsiness

C.   Dehydration

D.   Air hunger

E.    Abdominal pain

 

5) Commonest cause of coma in a diabetic is:

A.   Diabetic ketoacidosis

B.   Lactic acidosis

C.   Hyperosmolar coma

D.   Hypoglycaemia

E.    Uraemic coma

 

6) Neurological features of myxoedema include all of the fallowing except:

A.   Delayed relaxation of ankle jerk

B.   Cerebellar ataxia

C.   Hypertonia

D.   Coma

E.    Carpal tunnel syndrome

 

7) Myxoedema coma is characterised by:

A.    Hypertension

B.     Tachycardia

C.     Euthermia

D.    Hypoventilation

E.     Extensor plantar response

 

8) Commonest cause of unilateral exophthatmos is:

A.    Cavernous sinus thrombosis

B.     Retrobulbar tumour

C.     Chloroma

D.    Thyrotoxicosis

E.     Pseudotumor cerebri

 

9) 'Microalbuminuria' is urinary albumin excretion ratio between:

A.   10-100 µg/min

B.   20-200 µg/min

C.   30-300 µg/min

D.   40-400 µg/min

E.    50-500 µg/min

 

10) Sleeping pulse rate is not increased in:

A.    Anxiety neurosis

B.     Rheumatic carditis

C.     Pulmonary tuberculosis

D.    Atropinised patient

E.     Depression

 

11) Which is not a feature of autonomic neuropathy in diabetes:

A.   Retrograde ejaculation

B.   Gustatory sweating

C.   Mononeuritis multiplex

D.   Hypoglycaemic unresponsiveness

E.    Postural hypertension

 

12) Beta-blockers can be used in all except:

A.    Glaucoma

B.     Bronchial Asthma

C.     Anxiety states

D.    Angina pectoris

E.     Migraine

 

13) Cardiovascular findings of thyrotoxicosis do not include:

A.   Loud S1

B.   Palpitation

C.   Water-hammer pulse

D.   Ejection click

E.    Pericardial effusion

 

14) Acromegaly is associated with all of the following except:

A.    Acanthosis nigricans

B.     Fibromata mollusca

C.     Micrognathia

D.    Cardiomegaly

E.     Excessive sweating

 

15) Cushing's syndrome does not give rise to:

A.    Hirsutism

B.     Peripheral neuropathy

C.     Purple striae

D.    Acne

E.     Stunted growth

 

16) Sheehan's syndrome presents with:

A.   Cardiac failure

B.   Persistent lactation

C.   Fever

D.   Striking cachexia

E.    Amenorrhea

 

17) Hypocalcaemia is produced by all except:

A.    Hysterical hypoventilation

B.     Acute pancreatitis

C.     Chronic renal failure

D.    Osteomalacia

E.     Hypoproteinaemia

 

18) Gynaecomastia may be produced after treatment with all except:

A.   Spironolactone

B.   Digitalis

C.   Cimetidine

D.   Rifampicin

E.    INH

 

19) Primary hyperaldosteronism is not featured by:

A.    Diastolic hypertension

B.     Paraesthesia

C.     Alkalosis

D.    Oedema

E.     Hypokalaemia

 

20) Thyrotoxicosis may be featured by all except:

A.   Myopathy

B.   Pretibial myxoedema

C.   Hypernatraemia

D.   Atrial fibrillation

E.    Ophthalmopathy

 

21) Which of the following is not associated with hypothyroidism:

A.    Loss of libido

B.     Weightless

C.     Cardiac failure

D.    Organic pyschosis

E.     Menorrhagia

 

22) All of the following are featured by dermal hyperpigmentation except:

A.   Conn's syndrome

B.   Bronchogenic carcinoma

C.   Addison's disease

D.   Haemochromatosis

E.    Nelson’s syndrome

 

23) Hyperparathyroidism is not featured by:

A.    Acute pancreatitis

B.     Nephrocalcinosis

C.     Palpable neck swelling

D.    Pseudogout

E.     Hypocalcaemia

 

24) Phaeochromocytoma is not associated with:

A.   Weight gain

B.   Fear of death (angor animi)

C.   Paroxysmal hypertension

D.   Constipation

E.    Sweating

 

25) Features of Addison's-disease do not include:

A.    Diarrhoea

B.     Dizziness

C.     Dermatitis

D.    Dehydration

E.     Lymphocytosis

 

26) Pseudohypoparathyroidism is not associated with:

A.    Cataract

B.     Raised level of plasma PTH

C.     Mental retardation

D.    Reduced level of plasma phosphate

E.     Short stature

 

27) All of the following are noted in Cushing's syndrome except:

A.    Psychosis

B.     Systemic hypertension

C.     Sexual precocity

D.    Osteoporosis

E.     Hirsutism

 

28) Secondary hyperaldosteronism is associated with all except:

A.    Congestive cardiac failure

B.     Nephrotic syndrome

C.     SIADH

D.    Cirrhosis of liver

E.     Renal artery stenosis

 

29) All of the following drugs may produce galactorrhoea except:

A.    Salicylates

B.     Reserpine

C.     Cimetidine

D.    Methyldopa

E.     Metoclopramide

 

30) 'Brown tumor' of bone is found in:

A.    Primary hyperparathyroidism

B.     Pseudohypoparathyroidism

C.     Secondary hyperparathyroidism

D.    Hyperparathyroidism

E.     Ewing sarcoma

 

31) Primary aldosteronism is not featured by:

A.    Low plasma rennin

B.     Hypokalaemia

C.     Oedema

D.    Systemic hypertension

E.     Adrenal hyperplasia

 

32) Vanillylmandelic acid (VMA) excretion is increased in urine in:

A.   Conn's syndrome

B.   Congenital adrenal hyperplasia

C.   Testicular feminization syndrome

D.   Phaeochromocytoma

E.    Vipoma

 

33) Commonest cause of thyrotoxicosis is:

A.    Multinodular goiter

B.     Hashimoto's thyroiditis

C.     Graves' disease

D.    Well-differentiated carcinoma

E.     Toxic adenoma

 

34) In pregnancy, anti-thyroid treatment of choice is:

A.    Radio-active iodine

B.     Carbimazole

C.     Subtotal thyroidectomy

D.    Corticosteroid

E.     Propylthiouracil

 

35) Anorexia nervosa is not associated with:

A.    Hypokalaemia

B.     Primary amenorrhoea

C.     Exclusively in females

D.    Low FSH and LH

E.     ↑ thyroxin level

 

 

Answer key :

1.     C

2.     B

3.     C

4.     A

5.     D

6.     C

7.     D

8.     D

9.     B

10.                        A

11.                        C

12.                        B

13.                        D

14.                        C

15.                        B

16.                        D

17.                        A

18.                        D

19.                        D

20.                        C

21.                        B

22.                        A

23.                        C

24.                        A

25.                        C

26.                        D

27.                        C

28.                        C

29.                        A

30.                        A

31.                        C

32.                        D

33.                        C

34.                        B

35.                        C

 

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