Endocrinology Module 3

A 45 year old female presents feeling unwell with weight loss, throat pains and palpitations. These symptoms have developed over the last two weeks and she has lost approximately 3kg in weight. There is no other past medical history of note. She is a smoker of 10 cigarettes per day and drinks approximately 10 units of alcohol weekly. She is employed as a cleaner. Of note in her family history is a maternal grandmother who receives treatment for an underactive thyroid.

On examination she has a temperature of 37.5oC, a fine tremor of the outstretched hands, a pulse of 98 beats per minute regular and a blood pressure of 120/80 mmHg. She has evidence of lid lag but no exophthalmos. Examination of her neck reveals a tender goitre but no palpable lymphadenopathy. No bruit is audible over the goitre. Auscultation of the heart and lungs are both normal and no masses are palpable on abdominal examination.

Investigations reveal

Full Blood Count Normal
ESR 88 mm/hr
Urea and Electrolytes Normal
Calcium 2.32 mmol/l (2.2 – 2.6)
Free T4 45.4 nmol/l (10-23)
TSH 0.05 mu/l (0.5-5)
Anti Thyroid peroxidase antibody- undetectable.
Anti-thyroglobulin antibodies- low normal

What is the most likely diagnosis?

DeQuervain's (subacute) thyroiditis

Correct Incorrect Correct answer

Graves' Disease

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Hashimoto's thyrotoxicosis

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Papillary Thyroid cancer

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Riedel's thyroiditis

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Which of the following is not true regarding Fibroblast Growth Factor 23(FGF 23)/Phosphatonin?

Action is dependent on parathyroid hormone

Correct Incorrect Correct answer

Regulates phosphate homeostasis

Correct Incorrect Correct answer

Decreases expression of renal tubular sodium-phosphate transporter(NPT2a)

Correct Incorrect Correct answer

Decreases serum 1,25(OH)2D3

Correct Incorrect Correct answer

Serum levels rise in response to a rise in serum phosphate

Correct Incorrect Correct answer

Which of the following is not an appropriate physiological response to high serum phosphate?

Decreased serum PTH

Correct Incorrect Correct answer

Increased serum FGF-23

Correct Incorrect Correct answer

Decreased synthesis of 1,25(OH)2D3

Correct Incorrect Correct answer

Reduced expression of sodium phosphate co transporter(NPT2a)

Correct Incorrect Correct answer

Inhibition of 1 alpha hydroxylase enzyme activity

Correct Incorrect Correct answer

A 25 year old nurse is brought to the emergency department by a friend who has discovered her with altered mental state.

She is found to have hypoglycemia but does not have a history of diabetes mellitus.

Lab findings:

Blood glucose 1.7mmol/l
serum insulin high
serum C peptide low

What is the most likely diagnosis?

Exogenous insulin overdose

Correct Incorrect Correct answer

Sulphonylurea overdose

Correct Incorrect Correct answer

Insulinoma

Correct Incorrect Correct answer

Addison's disease

Correct Incorrect Correct answer

Undiagnosed type 1 diabetes mellitus

Correct Incorrect Correct answer

A 60-year-old male presents with central weight gain, hypertension, and diabetes. He has a history of asthma treated with inhaled corticosteroids. He drinks two standard drinks of alcohol/day. On examination he has central obesity, thin skin, and proximal muscle weakness.

The following test results are obtained:

24 hour urinary free cortisol is 1400 nmol/day [ 11 – 110 nmol/l]
0900 plasma adrenocorticotrophic hormone (ACTH) is 15 pmol/L [3 -20 pmol/L]
80 percent reduction in plasma cortisol with high dose dexamethasone suppression test.
Magnetic resonance imaging (MRI) pituitary is normal

Which of the following is the most likely cause of this man’s presentation?

Cushing's disease

Correct Incorrect Correct answer

Exogenous glucocorticoid administration.

Correct Incorrect Correct answer

Pseudo-Cushing's syndrome

Correct Incorrect Correct answer

Ectopic Cushing's syndrome

Correct Incorrect Correct answer

Cortisol producing adrenal adenoma

Correct Incorrect Correct answer

Which of the following gene mutation is the most common cause of monogenic diabetes?

HNF-1 alpha

Correct Incorrect Correct answer

HNF-4 alpha

Correct Incorrect Correct answer

Glucokinase

Correct Incorrect Correct answer

IPF-1

Correct Incorrect Correct answer

HNF-1b

Correct Incorrect Correct answer

Which of the following type of monogenic diabetes is most sensitive to sulphonylurea?

HNF-1 alpha

Correct Incorrect Correct answer

HNF-4 alpha

Correct Incorrect Correct answer

Glucokinase

Correct Incorrect Correct answer

IPF-1

Correct Incorrect Correct answer

HNF-1 beta

Correct Incorrect Correct answer

The thyroid technetium scintiscan shown above demonstrates globally reduced/absent tracer uptake. This pattern is unlikely to be seen in which of the following conditions?

Graves disease

Correct Incorrect Correct answer

Subacute thyroiditis

Correct Incorrect Correct answer

Thyroxine therapy

Correct Incorrect Correct answer

Amiodarone therapy

Correct Incorrect Correct answer

Postpartum thyroiditis

Correct Incorrect Correct answer

A 40-year-old man presents with weight loss, heat intolerance and tremor. On examination he has a small non-tender diffuse goiter and is clinically thyrotoxic.

The following results are obtained:

Free T4 36 pmol/L [10-23]
Free T3 12.5 pmol/L [2.8-6.8]
thyroid-stimulating hormone (TSH) is suppressed.
anti-microsomal antibodies 1:1600 [<1:400]

A technetium scan is as shown below.

What is the most likely diagnosis?

silent thyroiditis.

Correct Incorrect Correct answer

Graves' disease.

Correct Incorrect Correct answer

toxic multinodular goiter

Correct Incorrect Correct answer

subacute thyroiditis.

Correct Incorrect Correct answer

Hashimoto's thyroiditis

Correct Incorrect Correct answer

An 82-year-old woman presents with a swelling in the neck which has been present for two years and has recently increased in size. There are no other symptoms.

The patient is clinically euthyroid and has a regular pulse of 80/minute. A firm, non-tender 4 cm nodule is palpable in the upper portion of the right lobe of the thyroid gland. The left lobe is slightly enlarged. There is no lymphadenopathy. The heart, chest and abdomen are normal.

Serum free thyroxine (free T4) is 23 pmol/L [10-19] and thyroidstimulating hormone (TSH) is 0.02 mU/L [0.30-4.30].

The technetium-labelled thyroid isotope scan is shown below.

What is the most likely diagnosis?

Toxic multinodular goitre.

Correct Incorrect Correct answer

Painless thyroiditis.

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Thyroid cyst.

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Hyperfunctioning (toxic) adenoma.

Correct Incorrect Correct answer

Thyroid carcinoma.

Correct Incorrect Correct answer

An 18-year-old woman with type 1 (insulin-dependent) diabetes mellitus is at most risk of developing which of the following conditions?

Hashimoto's thyroiditis

Correct Incorrect Correct answer

Addison's disease.

Correct Incorrect Correct answer

Pernicious anaemia

Correct Incorrect Correct answer

Primary ovarian failure.

Correct Incorrect Correct answer

Systemic lupus erythematosus (SLE).

Correct Incorrect Correct answer

A 30-year-old woman presents with a 4 cm solitary thyroid nodule.

What is the most appropriate initial investigation to do?

Serum thyroid-stimulating hormone (TSH).

Correct Incorrect Correct answer

Fine needle aspiration biopsy.

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Thyroid ultrasound.

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Technetium scan.

Correct Incorrect Correct answer

Serum calcitonin.

Correct Incorrect Correct answer

Which of the following instructions should be provided to a patient taking alendronate for the treatment of osteoporosis to maximize its efficacy and minimize potential gastrointestinal side effects?

Take alendronate first thing in the morning, before eating or drinking anything else, including other medicines

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Take alendronate last thing before bedtime.

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Take alendronate at bedtime or while lying in bed.

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Take alendronate with mineral water, tea, coffee, milk or juice.

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Lie down for at least 30 minutes after taking Alendronate.

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The following intervention are all helpful in preventing renal impairment associated with Zoledronic acid, except:

Concurrent use of diuretic.

Correct Incorrect Correct answer

Measuring Creatinine clearance before each dose.

Correct Incorrect Correct answer

Avoid in patients with a creatinine clearance < 35 mL/min.

Correct Incorrect Correct answer

Monitoring renal function in at-risk patients.

Correct Incorrect Correct answer

Provide adequate hydration prior to administering zoledronic acid.

Correct Incorrect Correct answer

Which of the following best describes the mechanism of action of the thiazolidinediones?

Increased insulin sensitivity.

Correct Incorrect Correct answer

Increased insulin synthesis.

Correct Incorrect Correct answer

Stimulation of beta cell proliferation.

Correct Incorrect Correct answer

Stimulation of conversion of pro-insulin to C peptide.

Correct Incorrect Correct answer

Stimulation of insulin secretion.

Correct Incorrect Correct answer

A patient on alendronate for osteoporosis complains of hip pain.

What is the next step in management?

Request Hip x-rays to rule out fracture

Correct Incorrect Correct answer

Provide pain relief with NSAIDs

Correct Incorrect Correct answer

Reassurance

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Refer for physiotherapy

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Immediate referral to an orthopaedic surgeon

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A 36-year-old woman has been receiving olanzapine 15 mg/day for treatment of chronic schizophrenia for the last 12 months. She has been amenorrhoeic for six months and complains of weight gain of over 15 kg in that time. She has previously had a normal menstrual cycle. A pregnancy test is negative.

What is the most likely cause of the amenorrhea?

Hyperprolactinaemia.

Correct Incorrect Correct answer

Weight gain

Correct Incorrect Correct answer

An eating disorder

Correct Incorrect Correct answer

Amphetamine abuse

Correct Incorrect Correct answer

Premature menopause

Correct Incorrect Correct answer

What is most important reason for measuring thyroid stimulating antibodies in the third trimester of pregnancy in a woman with Graves disease?

Predict risk of neonatal thyrotoxicosis

Correct Incorrect Correct answer

Allow withdrawal of anti-thyroid medication

Correct Incorrect Correct answer

Detect foetal goitre

Correct Incorrect Correct answer

Guide dose adjustment of anti-thyroid medication.

Correct Incorrect Correct answer

Predict risk of flare of thyrotoxicosis post-partum.

Correct Incorrect Correct answer

What is the most significant risk of using Propylthiouracil in pregnancy?

Hepatotoxicity

Correct Incorrect Correct answer

Renal failure

Correct Incorrect Correct answer

Heart failure

Correct Incorrect Correct answer

Rash

Correct Incorrect Correct answer

Seizure

Correct Incorrect Correct answer

A 70-year-old man presents with lethargy, dizziness and reduced libido. Examination reveals reduced facial and body hair, bilaterally small firm testes, 10 ml each in volume, and a postural drop in his blood pressure from 130/80 mmHg to 100/60 mmHg. Magnetic resonance imaging of his pituitary shows a macro adenoma.

A deficiency of which pituitary hormone is most likely to explain his reduced libido?

Luteinising hormone (LH).

Correct Incorrect Correct answer

Adrenocorticotropic hormone (ACTH).

Correct Incorrect Correct answer

Prolactin.

Correct Incorrect Correct answer

Follicle stimulating hormone (FSH).

Correct Incorrect Correct answer

Growth hormone (GH).

Correct Incorrect Correct answer

Which of the following conditions is NOT associated with increased levels of Sex Hormone Binding Globulin (SHBG)?

Hyperthyroidism

Correct Incorrect Correct answer

Hypothyroidism

Correct Incorrect Correct answer

Hepatic cirrhosis

Correct Incorrect Correct answer

Arorexia nervosa

Correct Incorrect Correct answer

Pregnancy

Correct Incorrect Correct answer

A 40 year old patient presents with a thyroid nodule that has been increasing in size over the last month or so.Thyroid function tests are essentially normal with a positive anti-TPO antibody (other antibodies negative).

An USS is performed on the thyroid gland which reveals a >2cm heterogenous mass with otherwise normal thyroid tissue surrounding it.

What is the most appropriate management strategy?

Fine Needle Aspiration

Correct Incorrect Correct answer

Repeat USS in 6 months

Correct Incorrect Correct answer

Thyroid hormone replacement

Correct Incorrect Correct answer

CT neck

Correct Incorrect Correct answer

Tc99 uptake scan

Correct Incorrect Correct answer

Acromegaly is associated with which of the following malignancies?

Bowel cancer

Correct Incorrect Correct answer

Breast cancer

Correct Incorrect Correct answer

Testicular cancer

Correct Incorrect Correct answer

Head and neck cancer

Correct Incorrect Correct answer

Bladder cancer

Correct Incorrect Correct answer

A patient with panhypopituitarism is treated with thyroxine, testosterone injections, prednisone and desmopressin.

That following medication is likely to precipitate an Addisonian crisis:

Rifampicin

Correct Incorrect Correct answer

Dexamethasone

Correct Incorrect Correct answer

Hydrochlorothiazide

Correct Incorrect Correct answer

Entecavir

Correct Incorrect Correct answer

Eplerenone.

Correct Incorrect Correct answer

What is the most likely consequence of subclinical hypothyroidism?

Progression to overt hypothyroidism

Correct Incorrect Correct answer

Adverse cardiac endpoints

Correct Incorrect Correct answer

Systemic hypothyroid symptoms

Correct Incorrect Correct answer

Affects quality of life

Correct Incorrect Correct answer

Neuropsychiatric symptoms

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A patient presents with TSH of > 4.5 but normal T4 levels .

When should you repeat the test?

6 months

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3 months

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2 months

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4 months

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5 months

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A female patient is considering pregnancy . She was initially found to have TSH >4.5 but normal T4.

A repeat test in 3 months show a similar result.

What is the most appropriate next step in management?

Start treatment with thyroxine

Correct Incorrect Correct answer

Repeat test in 3 months

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Repeat test in 6 months

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Ignore the test result

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Repeat test in 1 month.

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A patient presents to the ED with symptoms of heart failure and AF is found to have TSH of <0.45 .

What is the most appropriate next step in management?

Check Free T4 and T3 levels and treat if elevated.

Correct Incorrect Correct answer

Repeat test with TSH, Free T4, T3 in 1 month.Treat if T4 or T3 are elevated.

Correct Incorrect Correct answer

Repeat test with TSH, Free T4 and T3 in 3 months.Treat if T4 or T3 are elevated.

Correct Incorrect Correct answer

Follow up in 12 months.

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Treat with carbimazole immediately.

Correct Incorrect Correct answer

A patient treated for Graves disease shows deranged liver function tests with cholestatic picture.

What would be the best explanation for this result?

Drug reaction secondary to Carbimazole

Correct Incorrect Correct answer

Drug reaction secondary to Propylthiouracil

Correct Incorrect Correct answer

Hepatitis B

Correct Incorrect Correct answer

Alcoholic hepatitis

Correct Incorrect Correct answer

Cholangitis.

Correct Incorrect Correct answer

A 55-year-old female patient presents to ED with sore throat and fever. She also complains of painful swelling in the scalp, neck and right hand.

She was diagnosed with hyperthyroidism 6 months ago and the condition was managed with oral carbimazole.

Further blood work up in ED have shown anaemia, leukopenia, neutropenia, lymphocytosis, eosinophilia along with increased ESR and C-reactive protein elevation.

What is her underlying diagnosis?

Agranulocytosis from Carbimazole

Correct Incorrect Correct answer

Systemic Lupus Erythematosus

Correct Incorrect Correct answer

Viral myalgia

Correct Incorrect Correct answer

Acute HIV infection

Correct Incorrect Correct answer

Anaphylactoid reaction to Carbimazole.

Correct Incorrect Correct answer

The following are poor prognostic features following treatment of Graves disease except?

Persistently low TSH receptor antibody with treatment

Correct Incorrect Correct answer

Large goitre

Correct Incorrect Correct answer

Severe biochemical disease

Correct Incorrect Correct answer

Increased T3/T4 ratio in serum

Correct Incorrect Correct answer

Male

Correct Incorrect Correct answer

Endocrinology Module 3

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