Endocrinology Module 1

An 80 year old female presents to the emergency department acutely unwell after being found unresponsive on the floor of her house by her son. She had a past history of hypothyroidism and was taking thyroxine daily. However, her compliance with treatment is questionable.

On examination, she was unrouseable with a Glasgow Coma Scale of 6/15, had a central temperature of 34oC, Oxygen saturations of 95% on air, a pulse of 44 beats per minute and a blood pressure of 100/80 mmHg.

Both plantar responses were extensor.

Prior to results of her emergency blood tests being available, what is the most appropriate immediate treatment for this patient?

Intravenous Levothyroxine (T4)

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Intravenous 50% Glucose

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Intravenous Hydrocortisone

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Intravenous Normal Saline

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Broad spectrum antibiotics

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A 33 year old nurse is admitted for prolonged fasting. She originally presented to clinic with a history of episodic sweating and light-headedness which had developed over a six month period with symptoms being entirely relieved by eating. She had developed one of these episodes whilst on the ward and a BM monitor showed a value of 2 mmol/l. She took some glucose tablets and had quickly recovered.

On examination, no specific abnormalities were found with a blood pressure of 118/74 mmHg, a pulse of 72 beats per minute and a BMI of 22 kg/m2. She was admitted for a 72 hour fast and at 3 am, 16 hours into the fast she develops typical symptoms.

Her BSL is measured at 2.2 mmol/l, the fast is stopped and bloods taken.

The following are her lab results:

Plasma Glucose 1.8 mmol/l (3 – 6)
Plasma 3-Beta-HydroxyButyrate 0.5 mmol/l (> 1 mmol/l)
Plasma Insulin 450 pmol/l (less than 21)
C-peptide 0.2 nmol/l (less than 0.5)

What is the most likely diagnosis?

Insulin treatment

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Sulphonylurea treatment

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Insulinoma

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Non-islet cell tumour hypoglycaemia

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Adult glycogen storage disease

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An 18-year-old girl with oligomenorrhoea since menarche at age 14 presents with a six month history of increasing facial hair and deepening of the voice. There is mild clitoral enlargement on examination. Laboratory results show:

serum testosterone 5.0 [1.0 – 2.5 nmol/L]
SHBG 18 [30 – 80 g/dl]
DHEAS 10 [3 – 12]

What is the next most appropriate investigation to help establish the diagnosis?

Pelvic ultrasound

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Dexamethasone suppression test

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GnRH suppression test

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Abdominal CT scan

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Adrenal venous sampling

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Empagliflozin is an established medication used in the treatment of Type 2 diabetes mellitus and is also indicated for heart failure and chronic kidney disease.

What is its primary mechanism of action?

Sodium glucose co-transporter 2 (SGLT-2) inhibitor.

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Sodium glucose co-transporter 1 (SGLT-1) inhibitor

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Glucagon-like peptide (GLP) agonist

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Dipeptidyl Peptidase-4 (DPP-4) inhibitor

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Alpha-glucosidase inhibitor

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The SGLT-2 inhibitor used in the treatment of Type 2 diabetes may cause the following adverse effect:

Ketoacidosis

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Severe Hypertension

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Hyperuricemia

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Heavy proteinuria

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Elevated HBA1c level

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

DPP-4 inhibitor

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GLP-1 receptor agonist

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Activation of the enzyme AMP-kinase

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Interaction with PPAR-gamma

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Reduces absorption of dietary carbohydrate.

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Liraglutide is an analogue of human glucagon-like peptide 1 (GLP-1) which has a promising role for patients with type 2 diabetes.

Liraglutide causes the following effect, EXCEPT?

Reduces the pulse rate

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Lowers blood glucose level

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Weight reduction

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Reduces blood pressure

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Reduces risk of cardiovascular disease in diabetic patients

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A diabetic patient is reported to have a Hemoglobin A1c level of 8.6% (based on the old DCCT format).

What is the new IFCC Hemoglobin A1c equivalent of this and the what is the closest mean glucose level (in mmol/l) that correlates with the above result?

Hemoglobin A1c of 65 and 10.4 mmol/L

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Hemoglobin A1c of 100 and 15.4 mmol/L

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Hemoglobin A1c of 80 and 9.6 mmol/L

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Hemoglobin A1c of 65 and 10 mmol/L

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Hemoglobin A1c of 90 and 13.9 mmol/L

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A previously well 53-year-old caucasian lady is found to have a 2 cm right adrenal mass when undergoing a computed tomography (CT) scan for suspected hepatobiliary disease. On examination, she has signs of Cushing’s syndrome with a blood pressure of 150/90 mmHg.

The following laboratory test results are obtained:

serum sodium 140 mmol/L [133-144]
serum potassium 3.8 mmol/L [3.5-5.0]
serum creatinine 0.10 mmol/L [0.05-0.11]
serum early morning cortisol 200 ug/dl [10 to 20]
serum adrenocorticotrophic hormone 1 ng/L [9 to 52]
serum dehydroepiandrosterone 300 ug/dl [35-430]
urinary catecholamines 0.3 μmol/24 h [<0.6]
urinary free cortisol 380 nmol/24 h [100-400]
plasma renin activity 1.5 nmol/L/h [0.4-2.3]

What is the most likely cause of the adrenal mass?

Cortisol producing adenoma

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Adrenal carcinoma

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Adrenal metastases

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Aldosterone producing adenoma

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Non-functioning adrenal adenoma

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In the diagnostic workup of Cushing’s syndrome, which of the following tests has the most limited utility in distinguishing between ACTH-dependent and ACTH-independent causes?

High dose dexamethasone suppression test

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Urinary free cortisol

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Plasma corticotropin

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Plasma cortisol measurements

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Low dose dexamethasone suppression test

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A 65-year-old woman with longstanding rheumatoid arthritis, previous DVT and osteoporosis presents with a mid thoracic crush fracture. She has a history of two previous crush fractures and has been taking alendronate 70mg weekly for three months and is tolerating this medication well. She has a normal serum calcium, phosphate, albumin and 25 hydroxy-vitamin D. She has taken prednisone in the past.

Which of the following treatment is most appropriate for future fracture prevention?

Continue alendronate.

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Continue alendronate and add raloxifene

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Cease alendronate and commence intravenous pamidronate

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Cease alendronate and commence romosozumab

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Cease alendronate and commence risedronate

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Assessing the anti-thyroglobulin antibodies is most useful in which of the following condition?

papillary thyroid cancer follow up

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multinodular goitre

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medullary thyroid cancer follow up

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Grave's disease

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neck pain

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In monogenic diabetes, the following statement are all correct about GCK mutation (MODY2) except?

Sensitive to sulphonylureas

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Isolated mild fasting hyperglycemia

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Not associated with microvascular complications in absence of glucose lowering medication

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Only 50% of mothers with GCK mutations will require insulin therapy during pregnancy if fetal growth is increased

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Absence of family history is common.

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The insulin analogue lispro (Humalog) has a more rapid onset of action compared to regular human insulin. This is because lispro:

does not form hexamers subcutaneously

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is a smaller sized molecule.

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is more lipophilic

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has greater affinity for the insulin receptor

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is less protein-bound

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Automated insulin delivery (AID) systems, also known as closed-loop or “artificial pancreas” technology, have become standard of care for many patients with Type 1 diabetes.

Which of the following best describes the expected outcomes with long-term use of current AID systems in adults?

Improved glucose control, reduced hypoglycaemia and lower glycated hemoglobin level.

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Improved glucose control but with increased risk of hypoglycemia, and higher glycated hemoglobin level.

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Improved glucose control and reduced hypoglycaemia but no effect on glycated hemoglobin level.

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No difference in glucose control but reduced hypoglycaemia and lower glycated hemoglobin level.

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Improved glucose control but with increased risk of hypoglycemia, with no effect on glycated hemoglobin level.

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An 15-year-old male of Māori descent has type 1 diabetes. He is brought to the Emergency Department at 3 a.m. on Friday morning following a hypoglycaemic convulsion. On questioning, his parents report that he has rugby training on Thursday afternoons before dinner.

His insulin regimen is long acting insulin and a short acting insulin analogue given together at breakfast and dinner.

Which of the following would be the best advice to avoid recurrent nocturnal hypoglycaemia after rugby training?

Reduce the long acting insulin dose at dinner

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Decrease his activity at rugby training

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Increase the fat content of his dinner after rugby training

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Reduce the long acting insulin dose at breakfast

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Reduce the short acting insulin dose at dinner

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What is the main site of Adiponectin production?

Adipose tissues

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Nerve tissues

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Cardiac muscle

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Renal parenchyma

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Adrenal gland

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Which of the following parameter is most likely to decrease in the first trimester of pregnancy?

TSH

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Total T4.

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Free T4

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Total T3

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Free T3

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In non thyroidal illness syndrome, which of the following is least likely to cause low T3 levels?

Dopamine

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High cortisol level

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Free fatty acids

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Amiodarone

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Propranolol

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A 28 year old man presents to the emergency department with 3 days history of fever, malaise, neck pain and odynophagia. He also described episodes of palpitations and tremors of his hands.

Blood test shows low TSH and High T4.

What is the most likely diagnosis?

de Quervain's thyroiditis

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Graves disease

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Solitary toxic adenoma

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Amiodarone induced thyrotoxicosis

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Postpartum thyroiditis

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Ultraviolet (UV) radiation (sunlight) acts on the skin to catalyse which of the following reaction?

7-dehydrocholesterol to vitamin D3 (cholecalciferol).

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25-hydroxyvitamin-D to 1,25-dihydroxyvitamin D

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Cholesterol to 7-dehydrocholesterol

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Vitamin D2 (ergocalciferol) to vitamin D3 (cholecalciferol).

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Vitamin D3 (cholecalciferol) to 25-hydroxyvitamin D.

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The activity of some hormones are affected by the levels of specific carrier proteins.

Therefore, which of the following hormone is going to have a clinically significant effect as a result of having abnormal levels of carrier proteins?

Testosterone.

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Adrenocorticotrophic hormone (ACTH).

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Cortisol.

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Growth hormone (GH)

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Parathyroid hormone (PTH).

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An asymptomatic patient presents for investigation of hypercalcaemia.

His mother has a similar diagnosis three years ago. She had a parathyroidectomy that was unsuccessful in treating her raised calcium level.

Serum Calcium is 2.8 (2.1 – 2.6 mmol/L), Phosphate is 0.8 (0.75- 1.45 mmol/L), PTH is normal.

What is the most appropriate investigation?

24 hour urine for urinary calcium excretion

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Genetic test for MEN-1

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Parathyroid gland imaging

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Serum ACE concentration

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Repeat PTH

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A 27-year-old woman with type 1 diabetes presents for review and reports frequent unexplained hypoglycaemic episodes in the past three weeks.

What is the most important test to do?

Beta-HCG

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HbA1c

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Celiac antibodies

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Continuous blood glucose monitoring

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TSH

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Which of the following patient group is least likely to benefit from oral Risedronate?

The 50 year old patient on 5mg of prednisone for a month.

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The 45 year old patient with a previous fragility fracture taking 10mg of prednisone for 12 months

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The 60 year old patient with a T-score of -1.5 on 8mg of prednisone for 6 months

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The 50 year old postmenopausal women with a T score of -2.5

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The 70 year old patient on 10mg of prednisone for 6 months.

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A 42-year old woman returned from a holiday in Greece in July. It is now 3 months following her return , but yet her tan has not yet faded. She has also noticed discolouration of her gums.She is on thyroxine for autoimmune thyroiditis and is fatigued despite being optimally replaced.

You suspect she has Addisons’s disease.

What would be the BEST test to perform to confirm the diagnosis?

ACTH challenge test (Synacthen test)

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Adrenal antibodies

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ACTH concentration

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Morning cortisol level

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24 hour urinary free cortisol

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What is the best marker of tumor recurrence following removal of papillary thyroid cancer?

Thyroglobulin

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TSH

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TSH receptor antibody

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T4

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Thyroxine peroxidase antibody

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What is the best investigation for persistent thyroid cancer?

Neck ultrasound and thyroglobulin.

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rhTSH stimulated thyroglobulin alone.

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Neck ultrasound

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Whole body scan

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Whole body scan and rhTSH stimulated thyroglobulin.

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A patient is highly suspected of having recurrent disease of his thyroid cancer following a high serum thyroglobulin. However his whole body scan was negative.

What should be the next step in management?

Arrange an FDG-PET.

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Repeat neck USS

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Repeat the serum thyroglobulin.

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Repeat FNA biopsy

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Follow up whole body scan in 3 months.

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Hyperemesis gravidarum is mostly associated with which condition?

Hyperthyroidism

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Hypercortisolism

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Growth hormone excess

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Hypoandrogenism

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Hyperprolactinemia

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Which of the following thyroid medication is associated with scalp defect(aplasia cutis) if used in pregnancy?

Methimazole

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Carbimazole

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Radioactive iodine

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Popylthiouracil

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Thyroxine

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In non thyroidal illness syndrome, which of the following factor is least likely to cause low T3 levels?

Dopamine

Correct Incorrect Correct answer

high cortisol level

Correct Incorrect Correct answer

Free fatty acids

Correct Incorrect Correct answer

Amiodarone

Correct Incorrect Correct answer

Propranolol

Correct Incorrect Correct answer

A 52-year-old woman presents with a 2.5 cm thyroid nodule discovered incidentally on carotid ultrasound. Fine needle aspiration biopsy reveals papillary thyroid carcinoma. She undergoes total thyroidectomy with central lymph node dissection.

Histopathology confirms a 2.8 cm classical papillary thyroid carcinoma with extrathyroidal extension into the strap muscles and metastatic disease in 4 of 12 lymph nodes. She receives radioactive iodine ablation therapy.

Eighteen months later, surveillance reveals a rising serum thyroglobulin level (85 ng/mL) with negative anti-thyroglobulin antibodies. Neck ultrasound shows no local recurrence. Diagnostic whole-body radioiodine scan is negative. FDG-PET/CT demonstrates multiple FDG-avid pulmonary nodules and a 1.5 cm mediastinal lymph node, consistent with radioiodine-refractory metastatic papillary thyroid carcinoma.

Molecular testing of the original tumour specimen is requested to guide systemic therapy options.

Which of the following molecular alterations, if detected, would make this patient a candidate for dabrafenib plus trametinib combination therapy?

BRAF V600E mutation

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RET fusion

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NTRK gene fusion

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RAS mutation

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TERT promoter mutation

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Endocrinology Module 1

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