Copy of 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?

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

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

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?

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?

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

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

The above thyroid technetium scintiscan is unlikely to be seen in:

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?

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?

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

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

What is the most appropriate initial investigation to do?

You have prescribed alendronate for a patient with osteoporosis.

What is the correct way of taking this medication?

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

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

A patient on alendronate for osteoporosis complains of hip pain.

What is the next step in management?

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?

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

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

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?

Which of the following condition is NOT associated with increased levels of free testosterone?

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?

Acromegaly is associated with which of the following malignancies?

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

That following medication is likely to precipitate an Addisonian crisis:

What is the most likely consequence of subclinical hypothyroidism?

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

When should you repeat the test?

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?

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?

A patient treated for Graves disease shows deranged LFTs with cholestatic picture.

What would be the best explanation for this result?

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?

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