ENDOCRINE-System

Wise 1700-by Sush and Team. 2016

Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal


Dear Plabber,


• This first ever System Wise 1700 document was created thanks to 3 months of daily hard work by the
PLAB Skype group ‘Unity’ which was brought together by Dr Susmita Chowdhury.
• Please ignore the old versions posted by my new skype member Murtaza as he did so without
permission.

The team members were:


& Susmita (Lead/most ignorant as she is working full time in public health for 13 years)

& Asad (Invaluable in IT and all types of support/the heart of the group)

& Manu (Volunteered to solve more questions/pathologist/amazing genuine person)
& Saima (Most concise clear notes/ photographic memory)
& Zohaib (Great research/a surgeon)
& Savia (Great research/multi-tasker with two little ones)
& Shanu (Very helpful after her March exam for those appearing in June)
& Mona (Great contributor in discussions)
& Manisha (Gyne/great discussion contributor)
& Sitara (Good discussion contributor)
& Samreena (Stayed a shorter time but great)
& Sami (Contributed the most early on but too brilliant for the group/still great friends)

& Komal (Knowledgeable sweet supportive girl)



• The main purpose was to break down the 1700 Q Bank System wise.



• We did our own reliable research for the options (OHCM/Patient info etc.) and concluded these keys
below on skype. This can save you 100s of hours of research. But I suggest you also do your own.

• 90% of the document consists of Unity research. We also added information from other circulating
documents and they are referenced as Dr Khalid/Dr Rabia (and her Team).

• However, several keys may be ‘incorrect’ and so please use your own judgment as we take no
responsibility. I suggest cross checking with Dr Khalid’s latest keys (a few of which are still debatable).
Finally decide on your own key.

• Sorry if some members failed to make their answers thorough. The highlights are mostly as per what
the team members wanted to highlight. Blank tables to be ignored.

• Note that some 1700 Questions are missing from here (when members did not do their share).
Questions may not be in order due to merging of documents and there is excess information than
required. Read as much as needed.

• This has been circulated by our team as a generous contribution to the Plabbers’ success and must
not be ‘sold’.



Good luck and best wishes: Sush and Team

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 ENDOCRINE-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal


Q:2 A 74yo smoker presented to his GP with cough and SOB. Exam revealed
pigmentation of the oral mucosa and also over the palms and soles. Tests
show that he is diabetic and hypokalemic.
What is the most probable dx?
a. Pseudocushing syndrome
b. Conns disease
c. Ectopic ACTH
d. Cushings disease
e. Hypothyroidism

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Ans. 1. The key is C. Ectopic ACTH.
Ans. 2. The patient is smoker and probably developed small cell lung cancer
which is working as a tumour producing ectopic ACTH resulting in
pigmentation. Resultant raised cortisol is leading to diabetes and hypokalemia.
the features can be explained by increased levels of ACTH and adrenocortical
hormones. So the question is : ectopic or pituitary ACTH excess? It seems to be
from an ectopic source since the patient is smoker and has SOB and cough (
Lung tumor whether small cell CA bronchus or carcinoid tumor- both may
secrete ectopic ACTH ) . Furthermore , Cushing's disease is often the result of
pituitary ACTH-secreting adenoma that also causes pressure symptoms like
headache and visual disturbances which are absent in this case.

Ectopic ACTH increase the secretion of aldosterone from adrenal gland and
aldosteronism causes hypernatraemia and hypokalaemia.

Cortisol is a form of stress hormone. So it induces glycogenolysis causing
increase in blood glucose.

No pigmentation in conn

Conns must have hypertension n not necessarily hypokalemia but it presents
with signs of hypokalemia like weakness quadriparsis cramps.

Why not Cushings?
SCLC is a direct cause of ectopic ACTH (statement is clear cut - Smoker).

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Further ectopic acth can lead to cushings at later stages but its major cause is
use of steroids and pituitary adenoma while ectopic acth is down the list.
And if cushings happen, the major indicative symptoms are stria, moon face,
easily fractured bones, plethora.

Diagnosis : Small Cell Lung CA causing ectopic ACTH.

Main reason : SMOKING for years. At Least 20 so age goes up to 50 to 60.
Male.

Symptoms :
Persistent cough, hemoptysis, chest n shoulder pains, SOB, clubbing. +/-
pleural effusion, pneumonia, pins and needles in arm n shoulder sensation.

Invs :
Initial : CXR. Shows shadowing
Confirmatory : CT chest THEN Biopsy thru bronchoscope (when central) or
transthoracic (when on the side) needle biopsy. Depends on the location.
Pleural Tap can be done if pleural effusion.

Treatment :
Surgery, radio and chemo.

Prognosis : Good if early diagnosed. Bad if late.


Q:142 142. A 60yo diabetic complains of pain in thigh and gluteal region on walking
up the stairs for the last
6 months. She is a heavy smoker and has ischemic heart disease. What is the
most appropriate
dx?
a. Thromboangitis Obliterans
b. Sciatica
c. DVT
d. Atherosclerosis
e. Embolus

Clincher(s)
A
B
C
D
E
KEY D
Additional
Information

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 ENDOCRINE-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Reference
Dr Khalid/Rabia Ans. 1. The key is D. Atherosclerosis.
Ans. 2. i) It is not sciatica as sciatica pain is worse when sitting. There may be
weekness, numbness, difficulty moving the leg or foot. A constant pain on one
side of the rear. A shooting pain that makes it difficult to stand up. ii) It is not
DVT as no swelling, warmth or redness of skin are there iii) It is not
thromboangitis obliterans as pulses are ok, no colour change or reduced hair
growth, no ulceration or gangrene iv) no embolism as no pain (rest pain), no
numbness, no redness or itching or rash, no ulceration of skin.
This patient has intermittent claudication due to atherosclerosis,
Symptoms Cramping pain is felt in the calf, thigh, or buttock after walking for a
given distance (the claudication distance) and relieved by rest. Ulceration,
gangrene, and foot pain at rest—eg burning pain at night relieved by hanging
legs over side of bed—are the cardinal features of critical ischaemia.
Fontaine classification for peripheral arterial disease: 1. Asymptomatic 2.
Intermittent claudication 3.Ischaemic rest pain 4. Ulceration/gangrene (critical
ischaemia)
Signs: Absent femoral, popliteal or foot pulses; cold, white leg(s); atrophic skin;
punched out ulcers (often painful); postural/dependent colour change; a
vascular
(Buerger’s) angle of <20° and capillary filling time >15s are found in severe
ischaemia
Imaging: Colour duplex USS is 1st line (non-invasive and readily available). If
considering
intervention then MR/CT angiography
MANAGEMENT: Stop smoking, exercise, treat HTN, antiplatelet (clopidogrel).
Advise exercise until maximum tolerable pain.
Vasoactive drugs may be used. If PAD is advancing consider:
Percutaneous transluminal angioplasty (PTA) is used for disease limited to a
single arterial segment.
Surgical reconstruction: arterial bypass
Amputation. If all fail. Knee should be saved if possible.


Q:170 A 38yo pt presented with tingling, numbness, paraesthesia, resp stridor and
involuntary spasm of the upper extremities. She has undergone surgery for
thyroid carcinoma a week ago. What is the most likely dx?
a. Thyroid storm
b. Hyperparathyroidism
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Hypocalcemia

Clincher(s)
A
B

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 ENDOCRINE-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

C
D
E
KEY E
Additional
Information

Reference
Dr Khalid/Rabia Ans. 1. The key is E. Hypocalcaemia.
Ans. 2. Hypocalcaemia may be due to accidental parathyroid gland removal
during thyroidectomy.
Ans. 3. Laryngospasm is a feature in hypocalcaemia which may cause stridor.
Thyroid storm causes thyrotoxicosis (inc heart rate, palpitations, weight loss,
tremors, heat intolerance etc) hyperparathyroidism causes hypercalcemia
(bone pains, kidney stones, confusion, psychosis), nerve injuries only explain

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

the stridor.
Causes of hypocalcemia:
Treatment
• Mild symptoms: give calcium 5mmol/6h PO, with daily plasma Ca2+ levels.
• In chronic kidney disease:May require alfacalcidol
• Severe symptoms: give 10mL of 10% calcium gluconate (2.25mmol) IV over
30min,
and repeat as necessary. If due to respiratory alkalosis, correct the alkalosis


Q:172 A 44yo pt has sudden onset of breathlessness and stridor few minutes after
extubation for thyroidectomy. The pat had longstanding goiter for which he
had the surgery. What is the most
likely dx?
a. Thyroid storm
b. Hematoma
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Tracheomalacia

Clincher(s)
A
B
C
D
E
KEY E
Additional
Information
Reference
Dr Khalid/Rabia Ans. The key is tracheomalacia (weakness of cricoid cartilarge which leads to
tracheal collapse which can lead to air obstruction)


Q:180 A 20yo pop star singer complains of inability to raise the pitch of her voice. She
attributes this to the thyroid surgery she underwent a few months back. What
is the most likely dx?
a. Thyroid storm
b. Bilateral recurrent laryngeal nerve injury
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Thyroid cyst

Clincher(s)
A
B

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 ENDOCRINE-System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia Ans. The key is D. External laryngeal nerve injury.
Complications of thyroid surgery:
1. Bleeding, which may cause tracheal compression.
2. Recurrent laryngeal nerve injury:
· Innervates all of the intrinsic muscles of the larynx, except the cricothyroid
muscle.
· Patients with unilateral vocal fold paralysis present with postoperative
hoarseness. Presentation is often subacute and voice changes may not present
for days or weeks. Unilateral paralysis may resolve spontaneously.
· Bilateral vocal fold paralysis may occur following a total thyroidectomy and
usually presents immediately after extubation. Both vocal folds remain in the
paramedian position, causing partial airway obstruction.
· Superior (external) laryngeal nerve injury:
o The external branch provides motor function to the cricothyroid muscle.
o Trauma to the nerve results in an inability to lengthen a vocal fold and thus
to create a higher-pitched sound.
o The external branch is probably the most commonly injured nerve in thyroid
surgery.
o Most patients do not notice any change but the problem may be career-
ending for a professional singer.
· Hypoparathyroidism: the resulting hypocalcaemia may be permanent but is
usually transient. The cause of transient hypocalcaemia postoperatively is not
clearly understood.
· Thyrotoxic storm: is an unusual complication of surgery but is potentially
lethal.
· Infection: occurs in 1-2% of all cases. Peri-operative antibiotics are not
recommended for thyroid surgery.
· Hypothyroidism.
· Damage to the sympathetic trunk may occur but is rare.


Q:810 A 45yo lady complains of expressable galactorrhea, decreased libido and
amenorrhea, weight
gain and easy fatigue. Her serum prolactin levels are 1100um/l. what is the
likely cause of
hyperprolactinemia?
a. Hypothyroidism
b. Stress
c. Pregnancy

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

d. Prolactin secreting pituitary tumor
e. PCOS

Clincher(s)
A
B
C
D
E
KEY D
Additional
Information
Reference
Dr Khalid/Rabia

Q:826 826. A young girl who is known to have T1DM presented with drowsiness and
deep breathing. Her
sugar level=20. Her BP=120/80mmHg and her mucous membranes are dry.
What would be the
next appropriate step?
a. Serum urea
b. Blood culture
c. CT
d. HbA1c
e. ABG

Clincher(s) Diabetic ketoacidosis, deep breathing occurs in acidosis
A
B
C
D
E
KEY E

Additional
Information
Reference
Dr Khalid/Rabia


Q:840 A known DM was admitted with sudden LOC. What is the initial inv?
a. CT scan
b. RBS
c. MRI
d. ECG

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

e. ABG

Clincher(s) No clincher about diabetic keto-acidosis – so not ABG
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia key : B
reason : diabetic pt >>> hypogycemia is common >>> RBS is the initial inv


Q:843 A pt was admitted with erectile dysfunction, reduced facial hair and
galactorrhea. What is the
most probable dx?
a. Hyperprolactinemia
. Cushi g s s d o e
c. Pheochromocytoma
d. Hyperthyroidism
e. Hypoparathyroidism

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia key : A
reason : galactorrhea + with erectile dysfunction + reduced facial hair
hyperprolactinaemia
Presentation
Women:
Common symptoms of are amenorrhoea, oligomenorrhoea and galactorrhoea.
They may also have infertility, hirsutism and reduced libido.
Men:
The hormonal effects of raised prolactin levels are subtle and develop slowly.
Endocrine symptoms are reduced libido, reduced beard growth and erectile

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

dysfunction.
Children:
Growth failure and delayed puberty are possible presentations in children.
Symptoms due to tumour size (usually macroprolactinomas):
Headache.
Visual disturbances (classically, a bitemporal hemianopia (lateral visual fields)
or upper temporal quadrantanopia).
Cranial nerve palsies.
Symptoms and signs of hypopituitarism.
Rarely, cerebrospinal fluid (CSF) leak or secondary meningitis.
Investigations
Initial investigations
TFTs.
Exclude pregnancy.
Basal serum prolactin:
If prolactin is mildly elevated (eg 400-1000 mU/L, normal range <400 mU/L), it
should be repeated before referral.
Dynamic prolactin stimulation tests, such as the TRH test, are not required.
Measurement of serum prolactin on three separate occasions (at least two
hours after rising and when the patient is rested) is sufficient.
A prolactin level >5000 mU/L usually indicates a true prolactinoma.
Further investigations
Visual field testing.
Pituitary imaging (preferably MRI
Assessment of pituitary function


Q:845 A 35yo man with T1DM is dehydrated with BP of 90/50mmHg. What is the
single most appropriate initial inv?
a. ABG
b. CBC
c. HbA1c
d. LFT
e. Serum Urea

Clincher(s) Diabetic ketoacidosis
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia key: a

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

reason : T1DM suspected to have DKA>>> ABG will show acidosis
DKA
DKA is characterised by hyperglycaemia, acidosis, and ketonaemia
DKA is normally seen in type 1 diabetics and may be a presenting feature of
undiagnosed type 1 diabetes, particularly in children. However DKA may rarely
occur in type 2 diabetics
Check capillary blood glucose and blood gases promptly. If these suggest
diabetic ketoacidosis (DKA) then immediately begin resuscitation and
management.
management:
• Immediate resuscitation as required
• Correct dehydration >>> 0.9% sodium chloride solution is the recommended
fluid of choice
• Insulin therapy >>> A fixed-rate IV insulin infusion calculated on 0.1 units/
per kilogram infusion is recommended.
• Metabolic treatment
• Treat any precipitating illness


Q:846 In OGTT what is the glucose venous plasma level 2h after glucose intake
which indicates impaired glucose tolerance?
a. >11.1mmol/l
b. Between 7.8-11.0mmol/l
c. Between 8.0-10.9mmol/l
d. Between 10.0-11.0mmol/l
e. Between 7.1-11.0mmol/l

Clincher(s)
A
B
C
D
E
KEY ANSWER is B.
Additional
Information
Reference
Dr Khalid/Rabia

Q:1534 A 60yo DM pt presented with easy fatigability, weakness and

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

numbness of hands and swollen feet. Exam: pedal edema, sensory
neuropathy and palpable liver and spleen. Urine: proteinuria.
US abdomen: enlarged kidney. Renal biopsy: amorphous homogenous
substance that stained
red with congo-red. What is the dx?
a. DM retinopathy
b. Sarcoidosis
c. Wilms tumor
d. Amyloidosis
e. Glycogen storage disease
Amyloidosis= all gol gol ☺
Clincher(s)
A
B
C
D
E
KEY D
Additional
Information
Reference
Dr Khalid/Rabia Answer: D (Aggregation of the congo-red dye and binding to amyloid
fibrils tends to red-shift the absorption spectrum, whereas binding to
cellulose fibers has the opposite effect.) Apple-green birefringence of
Congo red stained preparates under polarized light is indicative for the
presence of amyloid fibrils.

Amyloidosis is a rare disease that results from accumulation of
inappropriately folded proteins (everywhere). These misfolded proteins
are called amyloids. When proteins that are normally soluble in water
fold to become amyloids, they become insoluble and deposit in organs
or tissues, disrupting normal function. The type of protein that is
misfolded and the organ or tissue in which the misfolded proteins are
deposited determines the clinical manifestations of amyloidosis.

Amyloid deposition in the kidneys can cause nephrotic syndrome,
which results from a reduction in the kidney's ability to filter and hold
on to proteins. In AA amyloidosis the kidneys are involved in 91-96% of
people,symptoms ranging from protein in the urine to nephrotic
syndrome and rarely renal insufficiency
Q:1539 A pt was admitted with increased frequency of passing urine, increased
thirst, weakness and
muscle cramps. What is the most probable dx?
a. Co s s d o e
. Cushi g s s d o e
c. Pheochromocytoma

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

d. Hyperthyroidism
e. Hypoparathyroidism

Clincher(s)
A Conn's syndrome---> increased aldosterone level ---> increased
Na & K exchange ---> hypokalaemia ---> nephrogenic DI ---> polyuria
,polydipsia
Hypokalaemia --->muscle weakness , cramps
Hypertension

(hypernatrimeia)

B
C
D
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia
Q:1624 1624. A 15yo man presents with bitemporal hemianopia and spade-like
hands. What is the definite test to confirm the dx?
a. Early morning growth hormone
b. Insulin tolerance test
c. OGTT with growth hormone measurements
d. Random insulin-like growth factor (IGF-1)
e. Short ACTH test

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Key: OGTT with growth hormone measurements (C)
Reason: The bitemporal hemianopia and spade-like hands point
towards this being acromegaly. The best initial test is insulin like
growth factors but the definitive test that confirms the diagnosis is
OGTT with serial growth hormone measurements. Early morning
growth hormone would be raised anyway, it is released in a pulsatile
manner, Short ACTH is used for Cushing’s disease and Insulin tolerance

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

test is not used for growth hormone or acromegaly assessment.
Discussion:
How is acromegaly diagnosed?
* A blood test can measure the level of growth hormone. However, a
single test is not reliable. This is because the levels of growth hormone
in the body fluctuate a lot throughout the day in all people. * The
diagnosis of acromegaly is made by a glucose tolerance test. In this test
you drink a sugar drink containing 75 grams of glucose. You then have a
series of blood tests over two hours. The glucose should lower the
blood level of growth hormone. However, if you have acromegaly, the
growth hormone level remains high.
* A blood test to measure the level of IGF-1 (see above) may be
measured if acromegaly is suspected. This may also be used as an index
of disease activity to assess how well treatment is working. * A
magnetic resonance imaging (MRI) scan can show the size of any
tumour.
* Eye and visual tests can assess if the tumour is pressing on the optic
nerve.
* If you are confirmed as having acromegaly, other tests will be needed
to see if the tumour is causing a lack or excess of other hormones made
by the pituitary. * Other tests may include chest X-ray,
electrocardiogram (ECG) and X-rays of some of your joints.
What are the treatments for acromegaly?
The aim of treatment is to reduce the level of growth hormone in the
blood to normal, and to reduce the size of an enlarged tumour. Many of
the symptoms and features of acromegaly will reverse or improve with
successful treatment (apart from any fixed extra bone growth that had
occurred).
Surgical treatment
The most common treatment is to remove the adenoma by surgery.
This is done using very fine instruments. There are two different ways
to operate on the pituitary gland:
o The first method is known as endonasal trans-sphenoidal surgery.
This involves the surgeon reaching your pituitary gland through a small
cut (incision) in wall of one of your nostrils. In the other way, the
surgeon approaches the pituitary gland through a small incision behind
your upper lip, just above your front teeth. The instruments are passed
through the base of your skull - the sphenoid bone. The aim is to
remove the adenoma, but to leave the rest of the pituitary gland intact.
o The operation is successful, with no further treatment needed, in
around 9 out of 10 cases with smaller tumours. The operation is l
Q:1657 1657. You suspect Cushing's disease in a 50yo woman who has
attended clinic with glycosuria, HTN
and a suggestive body habitus. Initial inv point you towards a dx of
Cushing's disease. Which of
the following findings would be against this dx?

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a. A normal 8am cortisol
b. Failure to suppress morning cortisol with dexamethasone
c. HTN requiring >2 antihypertensive agents
d. Impaired growth hormone response to glucose loading
e. Unilateral adrenal enlargement

Clincher(s)
A
B
C
D
E
KEY E
Additional Cushings is bilateral
Information
Reference
Dr Khalid/Rabia Key is E: Unilateral adrenal enlargement
Cushing’s disease
Bilateral adrenal hyperplasia from an ACTH secreting pituitary
adenoma.
Peak age 30-50 years, male female ratio 1:1
A low dose dexamethasone test leads to no change in plasma
cortisol but 8 mg may be enough

Q:1691 1691. A 29yo Afro-Caribbean man presents with a non-productive
cough mild aches in the ankles. The
symptoms have been present for 2m. His ESR is elevated. Ca: 2.69
mmol/l; PO43-: 1.20 mmol/l;
ALP: 80 iu/L. Serum 25(OH) D: 180 nmol/l.
Normal values for Calcium: 2.12-2.65mmol/l; Phosphate: 0.8-
1.45mmol/l; ALP 30-300iu/L;
Serum 25(OH) D: 20-105nmol/l; Urea: 2.5-6.7mmol/l; Creatinine: 70-
120μmol/l
a. Osteoporosis (all biochem N)
b. Thiazide diuretics (hyper cal)
c. Skeletal metastases (hyper cal)
d. Primary hyperparathyroidism
e. Hypoparathyroidism (hypo cal)
f. Osteomalacia (ca def, deform of bones)
g. Multiple myeloma (benz jones, etc)
h. Paget's disease of bone (alk PO4 very high)
i. Sarcoidosis (multisystem, skin, ca)
j. Hyperthyroidism

Clincher(s) 1. Afro-Caribbean
2. aches in the ankles
3. ESR is elevated
4. Ca: 2.69

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5. non-productive cough

A Afrocarabean: all S diseases- sickle cell, sarcoidosis
B
C
D
E
KEY I
Additional Afro-Caribbean origin, raised calcium, elevated ESR and vitamin D, dry cough, ankle
pain points towards sarcoidosis.
Information
high serum calcium and vitaminD with respiratory cpmplaints and arthralgia acute
presentation of sarcoidosis- Lofgren's syndrome.

Reference
Dr Khalid/Rabia
Q:476 476. A 28yo female presents with 1 wk hx of jaundice and 2d hx of
altered sleep pattern and moods.
She was dx with hypothyroidism for which she is receiving thyroxine.
TFT showed increased TSH.
PT=70s. What is the most probable dx?
a. Acute on chronic liver failure
b. Hyper-acute liver failure
c. Autoimmune hepatitis
d. Acute liver failure
e. Drug induced hepatitis

Clincher(s)
A
B fetor hepaticus,flapping tremor not present. Also it was mentioned
fulminant hepatic failure (what you are indicating by liver failure) is rare
in autoimmune hepatitis

C
D
E
KEY C
Additional Autoimmunity is probably the underlying mechanism of both hypothyroidism and
hepatitis.
Information

Reference
Dr Khalid/Rabia KEY- C
Autoimmune hepatitis may present as acute hepatitis, chronic hepatitis,
or well-established cirrhosis. Autoimmune hepatitis rarely presents as
fulminant hepatic failure. One third may present as acute hepatitis
marked by fever, hepatic tenderness and jaundice. Non specific
features are anorexia, weight loss and behavioural change (here altered

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sleep pattern and moods). There may be coagulopathy (here PT=70s.)
leading to epistaxis, gum bleeding etc. Presence of other autoimmune
disease like hypothyroidism supports the diagnosis of autoimmune
hepatitis.
Q:493 493. An 8yo boy is clinically obese. As a baby he was floppy and difficult
to feed. He now has learning
difficulties and is constantly eating despite measures by his parents to
hide food out of reach.
What is the most probable dx?
a. Cushi g s s d o e
b. Congenital hypothyroidism
c. Prader Willi syndrome
d. Lawrence moon biedel syndrome
e. Do s s d o e

Clincher(s)
A
B
C
D Laurence–Moon syndrome (LMS) is a rare autosomal recessive[1]genetic
disorder associated with retinitis pigmentosa, extra digits,spastic
paraplegia, hypogonadism and mental retardation

Laurance-moon synd. Night blindness due to retinitis

pigmentosa, polydactyly are important features (OHCS/8th/648). With
no emphasis on more common features, Oral-steroid induced (post
renal transplant) Cushing makes more sense.

E
KEY
Additional
Information
Reference
Dr Khalid/Rabia KEY- C
Prader Willi syndrome- congenital disorder caused by defect in
gene on chromosome 15. Characterized by hypotonia at birth, feeding
difficulties, poor growth and delayed development. At the beginning of
childhood, they present with obsessive eating and obesity, learning
difficulties, behavioural
problems and compulsive behavior such as picking on skin. Distinctive
facial features like triangular mouth, unusually fair skin and light-
coloured hair, almond shaped eyes and short forehead.

Q:506 506. A 10yo boy is clinically obese and the shortest in his class. He had a
renal transplant last year

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and his mother is worried that he is being bullied. What is the most
probable dx? (On steroids)
a. Cushi g s s d o e
b. Congenital hypothyroidism
. Pseudo ushi g s syndrome
d. Lawrence moon biedel syndrome
e. Do s s d o e

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia a. Cushing’s syndrome
he's on steroids post-renal transplant, Oral steroids is the chief cause of
Cushing's syndrome (OHCM, 8th, page 124).
Laurance-moon synd. Night blindness due to retinitis pigmentosa,
polydactyly are important features (OHCS/8th/648). With no emphasis
on more common features, Oral-steroid induced (post renal transplant)
Cushing makes more sense.
Congenital hypothyroidism Feeding difficulties, Somnolence, Lethargy,
Low frequency of crying, Constipation – macroglossia, neonatal
jaundice
Down’s syndrome he is clinically obese not conganital case,down
syndrome has cardaic problem and characteristic facial feature and
mentalyy retarded so it cant be option,these features are same for
lawrence moon but ptnt are mentally retarded whereas kid is studying
in normal school rather than special one
Pseudocushing’s syndromeit is mainly an idiopathic condition.Some
frequently occurring illnesses can induce a phenotype that largely
overlaps with Cushing syndrome and is accompanied by
hypercorticolism
Q:1175 1175. A 72yo presents with polyuria and polydipsia. The fasting blood
sugar is 8 and 10mmol/l.
BP=130/80mmHg and the level of cholesterol=5.7mmol/l. There is
microalbuminuria. What is
the single most appropriate next management?
a. ACEi and sulfonylurea
b. Statin and biguanide
c. Statin and glitazone
d. Insulin and ACEi

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e. Statin and ACEi

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia ACEI should be considered in diabetic patients , especially in those with
renal complications. A statin is considered in all diabetic patients above
the age of 40 years ( BNF ) . An oral hypoglycemic drug does not seem
to be needed since the sugar levels aren't that high and may respond to
lifestyle and dietary modifications alone.
when microalbuminuria is present , the target BP is 125/75. therefore ,
ACE-i should be given. Cholesterol is also raised , so statins
Diabetic pt, target BP <=130/80.
Diabetic pt plus microalbuminaria , target BP <=125/75.
1st line in diabetes RX is lifestyle modification than biguanides (if not
responding to 1st)
Q:1176 1176. A 49yo woman presents to the OPD. Her oral glucose test after
2h of glucose intake vs plasma
level in 2 different tests are 6mmol/l and 10mmol/l. This situation can
be categoraized as
a. Impaired glucose tolerance
b. Impaired fasting glucose
c. T1DM
d. T2DM
e. Metabolic syndrome

Clincher(s)
A
B
C
D
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia a. Impaired glucose tolerance
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l

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implies impaired fasting glucose (IFG)
Impaired glucose tolerance (IGT) is defined as fasting plasma glucose
less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to
7.8 mmol/l but less than 11.1 mmol/l
Diabetes UK suggests:
· 'People with IFG should then be offered an oral glucose tolerance test
to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but
above 7.8 mmol/l indicat

Q:1212 A 54yo male pt DM with BMI=33 who has been treated using dietary
control up till now presents to his GP with a fasting blood sugar of 14m
mol/l and creatinine=90mmol/l. Urine showsglycosuria. No other
abnormalities are found. What is the best next step in management?
a. Biguanide
b. Sulfonylurea
c. Insulin
d. Sugar free diet
e. ACE


Clincher(s) 54 YR,DM,BMI 33,FBS 14mmol/l
A Biguanide (Metformin) are first line treatment for type 2 Diabetes Mellitus. They
work by increasing insulin sensitivity. Additionally, they help with weight loss.
They do not cause hypoglycaemia

B Its not the first line
C
D
E
KEY
Additional
Information

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Reference Ohcm 199-202
Dr Khalid/Rabia NICE guidelines
1.Metformin
2.Metformin + Sulfonylureas
3.Add Thiazolidinedione or Insulin
4.Insulin + Metformin + Sulfonylureas
5.IIncrease Insulin dose as neede



Q:1232 1232. A diabetic has been prescribed a long acting hypoglycemic in the
morning and short acting in the evening. He takes a regular lunch, but hasbeen
having hypoglycemic attacks at around 4pm each day. Wh
at is the most appropriate intervention?
a. Recommend a heavier lunch
b. Review morning drug
c. Review evening drug
d. Review both drug
e. Reassure

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Clincher(s) LONG ACTING HYPOGLYCEMIC IN THE MORNING,HYPOGLYCEMIC ATTACKS
AT 4PM
A Recommending a heavier lunch carries the risk of increasing the blood sugar
B Since, the patient is on a long-acting hypoglycemic agent, and
experiencing hypoglycemic attacks at around 4 pm, this means that the
drug being used in the morning must be reviewed for appropriate
intervention and replacement.

C Reviewing the evening drug has no use since the patient does not experience
any hypoglycemic attacks after the evening drug until after he takes the
morning drug

D
E This patient cannot be reassured as he is having hypoglycemic attacks
for which an intervention is necessary.

KEY B
Additional
Information
Reference
Dr Khalid/Rabia


Q:1290 An 8yo boy with a BMI=28 was admitted to a surgical ward following a
MVC (motor vehicle crush). He was found to have glycosuria. When he
recovered from his injury the glycosuria resolved. What is the single
most appropriate follow-up inv?
a. Fasting blood glucose conc
b. Glycosylated hemoglobin -HbA1c
c. OGTT
d. Random blood glucose conc
e. Serum cortisol con


Clincher(s) BMI 28,mvc,GLYCOSURIA
A FBS to differentiate btw Stress-Induced Hyperglycaemia and DM

B
C
D
E
KEY A (as they develop DM in 3 years after post stress glycosuria)
Additional Diagnosing diabetes[4]
Information
Although HbA1c testing is mainly used for monitoring blood sugar control in

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patients with diabetes, the World Health Organization (WHO) now
recommends that HbA1c can be used as a diagnostic test for diabetes, provided
that stringent quality assurance tests are in place and assays are standardised to
criteria aligned to the international reference values. An HbA1c of 48
mmol/mol (6.5%) is recommended as the cut-off point for diagnosing diabetes.
A value less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed
using glucose tests. One advantage of using HbA1c for diagnosis is that the test
does not require a fasting blood sample.

Situations where HbA1c is not appropriate for diagnosis of diabetes include:[5]

• Children and young people.

• Patients suspected of having type 1 diabetes.
• Patients with symptoms of diabetes for less than two months.
• Patients at high diabetes risk who are acutely ill.

Patients taking medication that may cause rapid glucose rise, eg steroids•
antipsychotics.
• Patients with acute pancreatic damage, including pancreatic surgery.
• Pregnancy.
• Presence of other factors that influence HbA1c and its measurement:

• Erythropoiesis:
o Increased HbA1c: iron, vitamin B12 deficiency, decreased
erythropoiesis.
o Decreased HbA1c: administration of erythropoietin, iron,
vitamin B12, reticulocytosis, chronic liver disease.
• Altered haemoglobin:
o Genetic or chemical alterations in haemoglobin:
haemoglobinopathies, HbF and methaemoglobin may increase or
decrease HbA1c.
• Glycation:
o Increased HbA1c: alcoholism, chronic kidney disease.
o Decreased HbA1c: aspirin, vitamin C and vitamin E, certain
haemoglobinopathies.
• Erythrocyte destruction:
o Increased HbA1c: increased erythrocyte lifespan, eg
splenectomy.
o Decreased HbA1c: decreased erythrocyte lifespan, eg
haemoglobinopathies, splenomegaly, rheumatoid arthritis or
drugs such as antiretrovirals, ribavirin and dapsone.
• Other factors:
o Increased HbA1c: hyperbilirubinaemia, alcoholism, large doses
of aspirin, chronic opiate use.

Reference PATIENT.INFO

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Dr Khalid/Rabia


Q:1316 A 34yo woman presents with truncal obesity, easy bruising, hyperglycemia,
high BP and depression. Which of the following inv’s will be most helpful in
localizing the cause for Cushing’s syndrome?
a. Serum cortisol
b. 24h urinary cortisol
c. Low dose dexamethasone suppression test
d. High dose dexamethasone suppression test
e. Overnight dexamethasone suppression tes


Clincher(s) Truncal obesity,easy bruising,hyperglycemia
A
B Investigations to confirm the presence of Cushing's syndrome :
The recommended diagnostic tests for the presence of Cushing's syndrome are
24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test
and late-night salivary cortisol.

C
D High-dose dexamethasone suppression test:
♣The 8 mg overnight dexamethasone suppression test and the 48-hour high-
dose dexamethasone test may be useful when baseline ACTH levels are
equivocal. They also help in determining whether a patient has pituitary or
ectopic ACTH production.
♣Greater than 90% reduction in basal urinary free cortisol levels supports
the diagnosis of a pituitary adenoma; ectopic ACTH causes lesser degrees of
suppression

E
KEY D

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Additional
Information

Reference ohcm page 216

Dr Khalid/Rabia


Q:1349 A 6m infant has breast milk jaundice. He is otherwise feeding well and
is not dehydrated. What would his LFTs look like?
a. Total bilirubin:40, conjugated bilirubin<5%
b. Total bilirubin:300, conjugated bilirubin 85%
c. Total bilirubin:500, conjugated bilirubin>85%
d. Total bilirubin:400, conjugated bilirubin<85%


Clincher(s) Breast milk jaundice,otherwise feeding well (it’s mainly unconjugated

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biliurin)
A the baby is well and the jaundice usually resolves by six weeks but occasionally
continues for up to month

B
C Breast milk jaundice will not have such high levels of total bilirubin. Plus the
majority would be unconjugated

D
E
KEY A
Additional In the breastfed infant, prolongation of unconjugated hyperbilirubinemia into
Information the third and later weeks of life in the healthy newborn is a normal and
regularly occurring extension of physiologic jaundice. This is known as
breastmilk jaundice (1,2)

• breast milk jaundice, benign unconjugated hyperbilirubinaemia

associated with breast feeding, is a common cause of prolonged jaundice
in the otherwise healthy breastfed infant born at term
• at least one third of all breastfed infants are clinically jaundiced in the
third week of life and that two thirds have significant unconjugated
hyperbilirubinemia in the third week (1)
• breast milk jaundice presents in the first or second week of life, and
can persist for as long as 12 weeks before spontaneous resolution (2)

Breast milk jaundice is a relatively common cause of prolonged neonatal

jaundice. It was thought to be due to a complex steroid in breast milk, 3-alpha,
20-beta pregnanediol, which inhibits hepatic glucuronyl transferase but no
definitive cause has been identified. Mild jaundice may last for weeks.

Diagnosis:

• recognition that at least two thirds of all breastfed infants will have
serum bilirubin concentrations in the third week of life that are
significantly higher than the adult normal value is an important
foundation for diagnosis
• diagnosis of breastmilk jaundice can usually be made in the healthy,
thriving breastfed infant with good weight gain in whom hemolysis and
other pathologic causes of jaundice have been ruled out by clinical or
laboratory study

Mangement:

• clinical management of the infant with breastmilk jaundice is of

considerable interest and importance
• interruption of breast feeding to diagnose breast milk jaundice is not
advised
o cessation of breast feeding, however brief, may jeopardise an
infant's ability to return to exclusive breast feeding, which is

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unnecessarily harmful to the infant and traumatic for parents
o a trial of breastfeeding cessation may be falsely reassuring
! may obscure a potentially serious underlying aetiology
for prolonged hyperbilirubinaemia e.g a breastfed infant
in whom breast milk jaundice occurs concomitantly with
G6PD deficiency may exhibit clinical improvement in
jaundice when breast feeding is discontinued, and a
potentially significant underlying condition may go
undiagnosed
• infants with breast milk jaundice require no treatment if clinically well
and if the total serum bilirubin concentration remains below that
recommended for phototherapy
o if total bilirubin exceeds 200 µmol/l (12 mg/dl), further
investigation and the diagnosis of breast milk jaundice alone
cannot be made. In the event of a negative investigation and
persistent hyperbilirubinaemia above 200 µmol/l (12 mg/dl),
then consider the possibility of the additional presence of an
UGT 1A1(uridine diphosphate glucuronosyltransferase 1A1)
mutation or G6PD deficiency
o for total serum bilirubin over 350 µmol/l (20 mg/dl), treatment
with phototherapy is recommended

Notes:

• in the hepatocyte, bilirubin undergoes conjugation via the hepatic

enzyme UGT 1A1 (uridine diphosphate glucuronosyltransferase 1A1)
• mothers should be encouraged to continue with breast feeding as the
condition resolves spontaneously
• breast milk jaundice may be confused for jaundice due to fluid
deprivation
o insufficient caloric intake resulting from maternal and/or infant
breastfeeding difficulties may also increase serum unconjugated
bilirubin concentrations. This is the infantile equivalent of adult
starvation jaundice. It is known as breastfeeding jaundice or
"breast-nonfeeding jaundice."
o great majority of full -term breastfed infants who developed
kernicterus had excessive weight loss of more than 10%,
suggesting a period of lethargy and poor feeding, possibly
secondary to the rising serum bilirubin

Reference Gp notebook
Dr Khalid/Rabia

Q:

Clincher(s)
A

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B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q: 732 A 60yo DM lady presents with severe peri-anal paiN and swelling . Whats͛ the
Cause?
a. Anal carcinoma
b. Anal fissure
c. Hemorrhoid
d. Anal abscess
All DM are immunocompromised, so org grows (most common staph aureus)
Clincher(s) DM elderly pt presents with perinatal pain and swelling
A
B
C
D
E
KEY D
Additional Diabetics patients are more prone to infection.
Information
Reference
Dr Khalid/Rabia The answer is anal abscess.
The lady is 60 years old and presents with perianal pain and swelling.
Firstly it is important to think of an infection in case of diabetics.
An anorectal abscess is a collection of pus in the anal or rectal region. It may

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be caused by infection of anal fissure/STD/blockage of anal glands.


Q:749 . A 60yo woman has tiredness. She has noticed that her skin looks permenantly
tanned and she describes dizziness on standing up (hypotension). What is the
single most likely electrolyte pattern to be found?
a. Na+=120mmol/L, K+=5.9mmol/L
b. Na+=125mmol/L, K+=2.9mmol/L
c. Na+=140mmol/L, K+=4.5mmol/L
d. Na+=150mmol/L, K+=3.5mmol/L
e. Na+=150mmol/L, K+=5.9mmol/

Clincher(s) Elderly pt presents with tiredness, dizziness on standing up and permanently
tanned skin points towards adrenal insufficiency.

A Hyponatremia and hyperkalamia
B
C
D
E
KEY A
Increased K and low sodium due to aldosterone deficiency. Tanning due to
increase ACTH. Management CHAF
Cortisol: hydrocortisone , aldosterone: fludrocortisone
Additional Initial symptoms of Addison's disease can include:
Information
fatigue (lack of energy or motivation),lethargy (abnormal drowsiness or
tiredness), muscle weakness,low mood (mild depression) or irritabilityloss of
appetite and unintentional weight loss, the need to urinate frequently,
increased thirst, craving for salty foods

Dehydration can also be an early sign of Addison’s disease. It's caused by lack
of the hormone aldosterone in your body, which is used to regulate the
balance of salt and water.

Later symptoms:

low blood pressure when you stand up, which can cause dizziness and
fainting ,feeling sick (nausea), vomiting, diarrhoea, abdominal, joint or back
pain,muscle cramps , chronic exhaustion, which may cause depression,
brownish discolouration of the skin, lips and gums (hyperpigmentation),
particularly in the creases on your palms, on scars or on pressure points, such
as your knuckles or knees, a reduced libido (lack of interest in sex),
particularly in women

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Reference
Dr Khalid/Rabia


Q:757 7. A 43yo woman has been feeling lethargic and tired. Her BP=160/90mmHg.
Bloods: Na+=140mmol/L, K+=3.1mmol/L. What is the most likely dx?
a. Cushing’s syndrome
b. Conn’s syndrome
c. Hyperparathyroidism
d. Renal disease
e. Pheochromocytom

Clincher(s) High BP, normal sodium and low potassium.
A Lemon on stick, central obesity, proximal muscle weakness, hyperglycaemia,
abdominal striae and high BP due to chronic glucocorticoid excess
B Conn syndrome is primary hyperaldosteronism (hypo kalemic metabolic
alkalosis). Na retained=HTN
C Hyper calcemia symptoms, decreased PO4 , increase ALP and either increase
or normal PTH
D Can present with similar picture (renin not mentioned here)
E Presents with episodic symptoms
KEY B
Additional
Information
Reference
Dr Khalid/Rabia The key is B. Conn’s syndrome. [It can also be cushing’s syndrome! So if we like
to be sure we have
to know aldosterone and rennin level. i) Renin low, aldosterone high- Conn’s
syndrome (primary
hyperaldosteronism) ii) Renin low, aldosterone low- Cushing’s syndrome iii)
Renin high, aldosterone
high- Renovascular disease (secondary hyperaldosteronism


Q:792 A female pt with HTN and serum K+=2.7mmol/l. which hormone would you be
looking for?
a. Aldosterone
b. Cortisol
c. Thyrotoxin
d. Renin
e. Testosterone


Clincher(s) Hypertensive female with low potassium
A Aldosterone increase serum sodium and decrease potassium in return
B Cortisol responsible for metabolism of carbohydrate, protein and lipid

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C Thyroid related
D Renin send the signal to angiotensin (which sends signal to aldosterone)
E Androgen so no role here.
KEY A
Additional
Information
Reference
Dr Khalid/Rabia The key is A. Aldosterone. [HTN and hypokalemia is seen in
hyperaldosteronism. So we should look
for aldosterone].



Q:804 A 40yo man complains of thirst and lethargy (symp of hypercalcemia). His
BP=140/90mmHg, corrected Ca2+=3.7mmol/l. What is the most appropriate
management at this stage?
a. IV fluids
b. Prednisolone
c. IV hydrocortisone
d. Calcium prep

Clincher(s) Pt presented with thirst and ,lethargy and Ca level is 3.7mmol/l
A
B
C
D
E
KEY A
Additional Despite correction pt still presenting with signs of hypercalcemia so IV fluids
Information should be administer to lower the calcium level.
Normal Ca value:2.12-2.65mmol/ litre
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information

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Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference

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Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia



Q: 641 A 34yo DM pt is undergoing contrast radiography. What measure should be
taken to prevent renal damage with contrast dye?
a. Reduce contrast dye
b. Plenty of fluids
c. NSAIDS
d. ACEi
e. IV dextrose

Clincher(s)
A
B
C
D
E
KEY B (N saline usually)
Additional
Information
Reference

Dr Khalid/Rabia


Q: 665 A 79yo woman has been dx with T2DM. Her BMI=22. RBS are 8 and 10mmol/l.
Her BP=130/80mmHg. Her fasting cholesterol=5.7mmol/l. She is currently
symptom-free but has microalbuminuria. What is the single most appropriate

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drug management?
a. ACEi and glibenclamide
b. ACEi and metformin
c. Statin and ACEi
d. Statin and glibenclamide
e. Statin and metformin

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia


Q: 708 A 46yo woman has weight gain, sensitivity to cold, pulse=50bpm, heart is
enlarged with murmur. What is the single most likely dx?
a. Hypothyroidism
b. Hyperthyroidism
c. Cushing’s syndrome
d. Addison’s disease
e. Pheochromocytoma

Clincher(s)
A
B
C
D
E
KEY A
Additional Hypo Leads to dilated progressive cardiomyopathy
Information
Reference
Dr Khalid/Rabia


Q:713 A 27yo woman with anxiety and weight loss has tachycardia, tremor and mild
proptosis. What single mechanism accounts for her weight loss?
a. Deficiency in thyroid hormone

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b. Increased level of calcitonin
c. Increased metabolic rate
d. Insulin resistance
e. Reduced caloric intake

Clincher(s)
A
B
C
D
E
KEY C
Additional In excess, it both overstimulates metabolism and exacerbates the effect of the
Information sympathetic nervous system, causing "speeding up" of various body systems
and symptoms resembling an overdose of epinephrine (adrenaline). These
include fast heart beat and symptoms of palpitations, nervous system tremor
such as of the hands and anxiety symptoms, digestive system hypermotility,
unintended weight loss.
Reference
Dr Khalid/Rabia


Q: 715 A 19yo man presents with weight loss, increasing thirst and increasing
frequency of going to the washroom. His father, grandfather and 2 sisters have
been dx with DM. What is the most likely type of DM this pt suffers from?
a. IDDM
b. NIDDM
c. LADA
d. MODY
e. DKA

Clincher(s)
A
B
C
D
E
KEY D
Additional
Information
Reference
Dr Khalid/Rabia

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Q: 726 A 40yo lady who has been a smoker since she was a teenager has the following
blood result: Hgb=19. What hormone should you check?
a. Aldosterone
b. Cortisol
c. Erythropoietin
d. T4
e. TSH

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Secondary polycythaemia due to COPD


Q: 341 A 54yo woman has presented with episodes of abdominal ache, vomiting and
postural hypotension. She also has a dark pigmentation of her skin. A dx of
Addison’s disease was made.
What is the most likely electrolyte abnormality expected in this pt?
a. High Na+, Low K+
b. Low Na+, High K+
c. Low Na+, Low K+
d. High Na+, High K+
e. Low Na+, Normal K+


Clincher(s)
A
B
C
D
E In Addison's disease K+ is high where Na+ is low. So It is B not E.

KEY Ans. The key is B. Low Na+, High K+. [ with Addison disease, the sodium,
chloride, and carbon dioxide levels are often low, while the potassium level is
high].

Additional
Information

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Reference
Dr Khalid/Rabia


Q: 354 An elderly pt who is known to have DM presents to the hospital with
drowsiness,
tremors and confusion. What inv should be done to help in further
management?
a. Blood sugar
b. ECG
c. Standing and lying BP
d. Fasting blood sugar
e. CT



Clincher(s)
A
B
C
D
E
KEY Ans. The key is A. Blood sugar.since he is known diabetic he may have gotten
hypoglycemic d/t his meds
Additional
Information
Reference
Dr Khalid/Rabia


Q: 369 A 34yo woman is referred to the endocrine clinic with a hx of thyrotoxicosis. At
her
1st
appointment she is found to have a smooth goiter, lid lag and bilateral
exophthalmos
with puffy
eyelids and conjunctival injection. She wants to discuss the tx of her thyroid
prb as she is
keen to become pregnant. What is the most likely tx you would advise?
a. 18m of carbimazole alone
b. 18m of PTU alone (Key)
c. A combo od anti-thyroid drug and thyroxine
d. Radioactive iodine
e. Thyroidectomy (always done in 2nd trimester)

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Clincher(s)
A A-carbimazol use in early pregnancy can cause birth defects

B B propylthiouracil : antithyroid drugs are the treatment of choice for
thyrotoxicosis in pregnancy.

Carbimazole has been associated with rare cases of embryopathy ( particularly
a skin defect known as aplasia cutis ) and should be avoided in the
first trimester.

PTU should be used in its place but , because of its potential hepatotoxicity ,
should be replaced with carbimazole from the beginning of the second
trimeste

C No point to use thyroxin when patient already has thyrotoxicosis..

D D. iodine can pass placenta and cause thyroide disorder in fetus
E E: If drug treatment do not effect then hyperthyroidectomy is indicated.
KEY B 18m of PTU alone.
Other drug option i.e Carbamazepine is teratogenic [can cause i) spina bifida
ii)cardiovascular malformations ETC . PTU is on the other hand relatively safe
in
pregnancy.
Additional Surgery is indicated if there is a large goiter , poor drug compliance or
Information recurrent thyrotoxicosis following drug therapy. Furthermore , the cause of
thyrotoxicosis in this patient is Grave's disease , which is an autoimmune
problem. Autoimmune diseases tend to remit during pregnancy , when the
maternal immune system is suppressed in order to allow fetal development by
preventing immune reactions against him.

Reference
Dr Khalid/Rabia


Q: 383 A 29yo woman presents to her GP with a hx of weight loss, heat intolerance,
poor conc and palpitations. Which of the following is most likely to be a/w dx
of thyroiditis aasociated with viral infection?
a. Bilateral exophthalmos
b. Diffuse, smooth goiter
c. Reduced uptake on thyroid isotope scan
d. Positive thyroid peroxidase antibodies
e. Pretibial myxedema

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Clincher(s) Weight loss , heat intolerance , palpitations , poor concentration, female
gender and the age.

A
B
C this is a condition of subacute thyroiditis (De-quervain thyroiditis)
usually following viral illness like mumps, adenovirus, coxsackie or influenza.
this condition is transient and will resolve within a span of 2 to 4 months.
often, the thyroid gland will be tender.

thyroiditis is associated with inflammatory damage to the thyroid follicular
cells , therefore hormone synthesis will be defective with subsequent
reduction in iodine uptake.
Diffuse smooth goiter in the presence of thyrotoxicosis is a feature of Grave's
disease.


D
E
KEY C. Reduced uptake on thyroid isotope scan.
DX De Quervain’s or subacute thyroiditis.

. Viral or subacute thyroiditis: diagnostic criteria: i) Features of
hyperthyroidism present.
ii) Pain thyroid, not mentioned. iii) Investigations: high esr (60-100) not
mentioned,
Reduced uptake of radioactive iodine by the gland.
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

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Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

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Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia



Q: 810 A 45yo lady complains of expressable galactorrhea, decreased libido and
amenorrhea, weight gain and easy fatigue. Her serum prolactin levels are
1100um/l. what is the likely cause of hyperprolactinemia?
a. Hypothyroidism
b. Stress
c. Pregnancy
d. Prolactin secreting pituitary tumor (prolactinoma)
e. PCOS

N prolactin : M<450 F <600 all reference values in OHCM: Reference Intervals

pg 774; anything above 1000 is tumor.

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Clincher(s) h/o glactorrhea, decreased libido, amenorrhea, and high prolactin level.

A only amenorrhea is suggestive for hypothyroidism.

B decreased libido and weight gain is suggestive for stress.
C amenorrhea is suggestive for pregnancy
D Correct diagnosis of current clinical presentation. Normal prolactin level: for
male- less than 450 u/l and in female- less than 600 u/l

Above 1000>tumor
E weight gain(obesity) is linked with PCOS.
KEY D- prolactin secreting tumor.

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Additional
Information

Reference OHCM pg 226
Dr Khalid/Rabia

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Q: 826 A young girl who is known to have T1DM presented with drowsiness and deep
breathing. Her sugar level=20mmol. Her BP=120/80mmHg and her mucous
membranes are dry. What would be the
next appropriate step?
a. Serum urea
b. Blood culture
c. CT
d. HbA1c
e. ABG

Clincher(s) T1 DM with drowsiness and deep breathing. (diabetic ketoacidosis)
A Others don’t have any role
B
C
D Used in normal ruling out of DM
E patient is suffering from DKA.
KEY E-ABG

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Additional
Information

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Reference OHCM
Dr Khalid/Rabia



Q: 840 A known DM was admitted with sudden LOC. What is the initial inv?
a. CT scan
b. RBS
c. MRI
d. ECG
e. ABG

FBS-<7
Impaired: 7-8
2 hr
RBS- <7.7
Clincher(s) Known DM with sudden LOC (should mention whether pt taking hypocemic
drugs)
A
B Always think hypoglycaemia until proven otherwise.
C
D
E
KEY B- RBS.

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Additional
Information

Reference OHCM
Dr Khalid/Rabia

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Q: 843 A pt was admitted with erectile dysfunction, reduced facial hair and
galactorrhea. What is the most probable dx?
a. Hyperprolactinemia
b. Cushi ng s disease.
c. Pheochromocytoma
d. Hyperthyroidism
e. Hypoparathyroidism

Clincher(s) H/o erectile dysfunction, reduced facial hair and galactorrhea.
A
B Hyperactive adrenal cortex leading increase glucocorticoids and
mineralocorticoids.
C hyperactive adrenal medulla leading to increase catecholamines.
D Increase thyroid activity,
E hypofunction of parathyroid.
KEY A- hyperprolactinemia. (usually caused by pituitary tumor)

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Additional
Information

Reference OHCM
Dr Khalid/Rabia



Q: 845 A 35yo man with T1DM is dehydrated with BP of 90/50mmHg. What is the
single most appropriate initial inv?
a. ABG
b. CBC

c. HbA1c
d. LFT
e. Serum Urea

Dehydration, low b/p, : DKA

LOC> hypoglycemia
Clincher(s) low blood pressure and dehydration in T1DM patients.

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A ABG to rule out DKA.
B
C
D
E
KEY A- ABG
Additional
Information
Reference
Dr Khalid/Rabia


Q: 846 In OGTT what is the glucose venous plasma level 2h after glucose intake which
indicates impaired glucose tolerance?
a. >11.1mmol/l
b. Between 7.8-11.0mmol/l
c. Between 8.0-10.9mmol/l
d. Between 10.0-11.0mmol/l
e. Between 7.1-11.0mmol/l

Clincher(s)
A
B
C
D
E
KEY B- between 7.8- 11.0 mmol/l

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Additional
Information

Reference DM – as per WHO criteria: polydipsia, polyuria, etc…
Dr Khalid/Rabia Random=Glucose after 2 hrs of taking meal or glucose


Q: 1429 A 45yo man presented to his GP with vague symptoms of headache, proximal
muscle weakness and nocturia. Test results show him to be severely HTN
(230/130mmHg) and hypokalemic. What
is the most probable dx?
a. Addiso n’s disease
b. Co nn s disease
c. Familial hyperaldosteronism
d. Cushi ng s disease
e. Cushi ng s s yndrome.

Clincher(s) high blood pressure, headache and proximal weakness, hypokalemia.

A adrenal insufficiency
B correct diagnosis
C Blood pressure is normal in familial hyperaldosteronism.
D ACTH dependent due to bilateral hyperplasia of adrenal gland.
E clinical state occur due to chronic glucorticoid production and loss of normal
feedback mechanism of hypothalamic pituitary-adrenal axis.
KEY B- Conn’s disease. (primary hyper aldosteronism) there is aldosterone
producing adenoma.

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Additional
Information

Reference Secondary: is renin angiotensinogen dependent- see above
Dr Khalid/Rabia



Q: 1442 A 35yo man with T1DM is dehydrated with BP=90/50mmHg. What is the single
most appropriate initial inv?
a. ABG
b. CBC
c. HbA1c
d. LFT
e. BUE

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Clincher(s) T1 DM with dehydration and low blood pressure.
A
B
C
D
E
KEY A- ABG for Diabetic ketoacidosis.
Additional
Information
Reference
Dr Khalid/Rabia



Q: 1459 A middle aged man presents with a lump in front of his neck which moves up
while swallowing. US shows a mass replacing the left lobe of thyroid. And
spread to the sternocleidomastoid and
adjacent muscles. What is the most probable dx?
a. Thyroid ca
b. Pharyngeal pouch
c. Bronchus ca
d. Thyroid cyst
e. Larynx ca

Clincher(s) lump neck and adherent to underlying tissue. (fixed)
A
B presents with swelling on the lateral side of neck and difficulty in swallowing.
Halitosis
C patients with hoarseness of voice. dysphasia
D midline swelling and cystic. Movement with tongue
E stridor.

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KEY A- thyroid carcinoma. (anaplastic is locally invasive others spread by blood or
lymph) follicular and anaplastic occurs more in elderly. Follicular is well
differentiated
Additional
Information

Reference OHCM 602
Dr Khalid/Rabia



Q: 1530 A 68yo lady with T2DM. Which drug should be prescribed?
a. Biguanides
b. Sulphonyl urea
c. Insulin
d. Lifestyle modifications

Clincher(s) first line treatment for type 2 diabetes mellitus.
A
B
C
D
E

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KEY A- Biguanides (metformin)
Additional
Information

Reference
Dr Khalid/Rabia

Q: 1532 A 48yo man has intermittent left sided lower abdominal pain and feels generally
unwell. He has lost his appetite and has lost weight. Temp=38.3C and he has
BP=190/100mmHg. what is the single most likely investigation which lead to
diagnosis?
a. Colonoscopy
b. Endomysial antibodies
c. Fasting serum glucose conc
d. TFT
e. US abdomen

clinchers unilateral lower abdominal pain, weight loss, high blood pressure
A
B

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C
D
E
KEY D- Ultrasound abdomen to rule out renal malignancy. (Renal cell ca perhaps)
Additional Other than obstruction and perforation: do USG (otherwise for those x rays)
Information
Dr Khalid/Rabia
Reference





Q: 407 A 67yo male presents with polyuria and nocturia. His BMI=33, urine culture =
negative for
nitrates. What is the next dx inv?
a. PSA
b. Urea, creat and electrolytes
c. MSU culture and sensitivity (if no3 positive= infection)
d. Acid fast urine test
e. Blood sugar


Clincher(s)
A
B
C
D
E
KEY E. blood sugar
Additional
Information
Reference
Dr Khalid/Rabia Age at presentation and class1 obesity favours the diagnosis of type2 DM].
since culture is -ve for nitrates, so uti is ruled out



Q: 410 A T2DM is undergoing a gastric surgery. What is the most appropriate pre-op
management?
a. Start him in IV insulin and glucose and K+ just before surgery

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b. Stop his oral hypoglycemic on the day of the procesure
c. Continue regular oral hypoglycemic
d. Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+
before
surgery
e. Change to short acting oral hypoglycemic



Clincher(s)
A
B Stop night before surgery
C Contraindicated
D D. stop oral hypoglycemic the previous night and start insulin with glucose
and potassium before surgery
E
KEY
Additional Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+
Information before surgery.

Reference
Dr Khalid/Rabia


Q: 415 A 60yo man with a 4y hx of thirst, urinary freq and weight loss presents with a
deep painless ulcer on the heel. What is the most appropriate inv?
a. Ateriography
b. Venography
c. Blood sugar
d. Biopsy for malignant melanoma
e. Biopsy for pyoderma



Clincher(s) 4 years history of thirst, urinary frequency, weight loss presents with a deep
painless ulcer on heel
A
B
C
D
E
KEY C. blood sugar
Additional
Information
Reference

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Dr Khalid/Rabia The patient probably developed diabetic foot].
the next step wd be doppler scan to assess the vascular status

DVT ulcers would be painful



Q: 587 An 18yo man presents to his GP with thirst and polyuria. Some 6m ago he had
a significant head injury as the result of a RTA. He is referred to the local
endocrine clinic. Which of the following results would be the most useful in
confirming the dx of diabetes insipidus after a water deprivation test (without
additional desmopressin)?
a. Plasma sodium of 126mmol/l
b. Plasma sodium of 150mmol/l
c. Plasma osmolality of 335mosmol/kg and urine osmolality of 700mosmol/kg
d. Plasma osmolality of 280mosmol/kg and urine osmolality of 700mosmol/kg
e. Plasma osmolality of 335mosmol/kg and urine osmolality of 200mosmol/kg


More diluted urine and higher conc of plasma

ADH less in DI
Clincher(s)
A
B
C
D
E
KEY e. Plasma osmolality of 335mosmol/kg and urine osmolality of
200mosmol/kg

Additional
Information
Reference
Dr Khalid/Rabia normal osmolality of plasma is somewhere around 285 to 295. Since water is
being lost plasma will be more concentrated hence osmolality more than
300. Urines normal osmolality is more than 600. Since urine is dilute
osmolality is much lower..so E is correct
In DI: urine osmolarity is low while plasma osmolarity is high.
In contrast, in SIADH, urine osmolarity is high while plasma osmolarity is low.
Water deprivation test: Deprived of water from morning 8am till 4pm: weight
patient and check serum osmolality, if > 300 go to second step

Classification of causes of diabetes insipidus on basis of water deprivation and

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DDAVP® response

Urine osmolality after Urine osmolality after Likely diagnosis

fluid deprivation DDAVP® (mOsm/kg)
(mOsm/kg)
<300 >800 CDI
<300 <300 NDI
>800 >800 Primary/psychogenic
polydipsia
<300 >800 Partial CDI or NDI or PP or
diuretic abuse

Q: 599 599. A 60yo diabetic pt on anti-diabetic medication developed diarrhea. What
is the most likely cause for his diarrhea?
a. Autonomic neuropathy
b. Infective
c. Celiac disease
d. Crohns disease


Clincher(s)
A
B
C
D
E
KEY a. Autonomic neuropathy

Additional
Information
Reference
Dr Khalid/Rabia In general people no autonomic neuropathy usually. Once a diabetic develop
autonomic neuropathy he gets diarrhea off and on due to his autonomic
neuropathy and it becomes the most comon cause for his diarrhea. So most
likely cause in this case would be Autonomic neuropathy.

Autonomic neuropathy{GI tract} causes dysfunctional motility / secretions
/absorption. ..leads to gasteroparesis(damage to vagus nerve ), ch:
diarrhea(neuronal damage to small intestine) ,,/constipation(colon nerves

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damage )...

>diarrhea can be due to metformin] it has very common GI side effects ..

Autonomic neuropathy
• Risk factors include hypertension and dyslipidaemia. It is more common
in females.
• May present with:
o Cardiac autonomic neuropathy, which has been linked to:[5]
! Resting tachycardia, postural hypotension, orthostatic
bradycardia and orthostatic tachycardia.
! Exercise intolerance.
! Decreased hypoxia-induced respiratory drive.
! Increased incidence of asymptomatic myocardial
ischaemia, myocardial infarction, decreased rate of
survival after myocardial infarction.
! Congestive heart failure.
o Genitourinary:
! Impotence, retrograde ejaculation, urinary hesitancy,
overflow incontinence.
! At least 25% of men with diabetes have problems with
sexual function.
! There is often no association with glycaemic control,
duration or severity of diabetes.
! Risk factors for erectile dysfunction include increasing
age, alcohol, initial glycaemic control, intermittent
claudication and retinopathy.
o Gastrointestinal:
! Nausea and vomiting.
! Abdominal distension.
! Dysphagia.
! Diarrhoea.
o Gustatory sweating, anhidrosis.


Q: 617 A 14yo girl is clinically obese. She has not started her periods yet and has
severe acne. Among
her inv, a high insulin level is found. What is the most probable dx?
a. Cushing’s syndrome
b. Grave’s disease
c. Acquired hypothyroidism
d. PCOS
e. Addison’s disease

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Clincher(s)
A
B
C
D
E
KEY D. PCOS
Additional
Information
Reference
Dr Khalid/Rabia 14 yr...primary amenorrhea, severe acne ,high insulin. ...All favours PCOS.
obesity hyperandrogenism(acne) hyperinsulinemia and amenorrhea
P' AM + Insulin Resistance. Both Cushing n PCOS have hyperglycaemia but in
Cushing's $, it's due to high glucocorticoids lvl, not coz of Insulin Resistance.
Features
• subfertility and infertility
• menstrual disturbances: oligomenorrhea and amenorrhoea
• hirsutism, acne (due to hyperandrogenism)
• obesity
• acanthosis nigricans (due to insulin resistance)

Investigations
• pelvic ultrasound: multiple cysts on the ovaries
• FSH, LH, prolactin, TSH, and testosterone are useful investigations:
raised LH:FSH ratio is a 'classical' feature but is no longer thought to be
useful in diagnosis. Prolactin may be normal or mildly elevated.
Testosterone may be normal or mildly elevated - however, if markedly
raised consider other causes
• check for impaired glucose tolerance


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

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Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

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Q: 867 A pt on insulin is booked in for a hernia operation. What is the most
appropriate management of insulin?
a. Give insulin and saline pre-op
b. Stop insulin for the duration of the op
c. Give IV insulin + dextrose + saline pre-op
d. Give insulin as usual pre-op
e. None


Clincher(s) Hernia operation and suitable management of insulin

With insulin, glucose, saline and K+ given (not given)
A
B Only in minor operation where only one meal is skipped.
C
D Need to be given with other substrate to avoid hypoglycaemia
E
KEY C
Additional If the starvation period is short that is skipping one meal only then insulin can
Information be stopped and this can be managed without insulin infusion.

If the starvation period is expected to require omission of more than one meal
then VRII (variable rate insulin infusion) along with substrate is necessary to
avoid DKA.

VRII : 50 units of actrapid (short acting) in 50 ml of 0.9% saline with 10%
glucose+ KCL
Page ohcm 591

Insulin requirement is increased in :
• Obesity
• Prolonged surgery
• Glucocorticoid treatment
• Infection
In general, emergency or non-elective cases must have blood glucose
controlled with insulin, glucose and potassium infusions as above with
special attention being given to rehydration before surgery
Reference www.diabetologist-abcd.org.uk (about surgery induced hyperglycemia)
Joint British Diabetes Societies Inpatient Care Group and patient info.
Dr Khalid/Rabia The key is C. Give IV insulin + dextrose + saline pre-op.


Q:871 A 75yo man who has DM and HTN experiences acute monocular blindness
which resolves after 1h. What is the most likely dx?
a. GCA

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b. Optic neuritis
c. Lacunar infarct
d. Pontine hemorrhage
e. Amaurosis fugax

Clincher(s) Acute monocular blindness resolves with in hour
A The most common symptom of giant cell arteritis (GCA) is a headache,
although some people also experience jaw pain and vision problems.
B Optic neuritis (ON) is inflammation of the optic nerve. Classically there is a
triad of clinical features - reduced vision (of varying severity), eye pain
(particularly on movement) and impaired colour vision.
C Motor, sensory or cerebellar symptoms but no eye symptoms.
D presentation may include:

decreased level of consciousness (most common)
long tract signs including tetraparesis
cranial nerve palsies
seizures
Cheyne-Stokes respiration

PIN point pupil

E a painless transient monocular visual loss (i.e., loss of vision in one eye that is
not permanent)> corticosteroid given if it does not resolve spontaneously
KEY E
Additional
Information
Reference
Dr Khalid/Rabia


Q:902 A 62yo man dx with T2DM with BMI=33. Lifestyle modifications have failed to
control blood sugar. Labs: urea=3.6mmol/l, creatinine=89mmol/l. what is the
next appropriate management?
a. Biguanide (increases sensitivity-does not cause hypoglycemia; others
increase release of insulin and can cause hypoglycemia)
b. Sulfonylurea
c. Insulin
d. Glitazone (increases other SE chances)
e. Sulfonylurea receptor binder


Clincher(s) BMI 33 life style modification have failed
A
B
C

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D
E
KEY A
Additional Biguanides are the first choice in T2DM
Information
Reference
Dr Khalid/Rabia Clincher : BMI = 33, failure of lifestlye modifications

If BMI is >25 and life style modifications have failed, start biguanides
If BMI is < 25, start sulfonylurea (ref??)



Q:913 A 68yo woman dx with T2DM and BMI=33. Lab: GFR=29 (low), urea=13,
creatinine=390mmol/L. what is the next appropriate management?
a. Biguanide
b. Sulfonylurea
c. Insulin
d. Glitazone
e. Sulfonylurea receptor binder

Clincher(s) BMI is 33, GFR is 29, Urea 13 and creatinine 390
A Avoid metformin if eGFR is <36ml/ min as it will lead to lactic acidosis. Also
stop if sepsis or MI and morning before GA
B Not helpful BC of high BMI
C Most appropriate here
D Again high BMI so not helpful here.
E Same as above.
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Clincher : BMI = 33, Creatinine = 390 mmol/L

Biguanides ... cant be given if creatinine is > 150mmol/L

Sulfonylurea / sulfonylurea receptor binder ... is given when BMI is < 25

Glitazone ... 2nd line drug which also causes wt.gain by water retention



Q:945 DM man feels hot, painful lump near the anal region. What is the most
probable dx?
a. Anal fissure
b. Abscess

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c. Hematoma
d. Wart
e. External hemorrhoids


Clincher(s) DM so more prone to infection. Plus hx of feeling hot.
A
B
C
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia Peri anal abscess present in High-risk groups include those with diabetes,
immunocompromised patients, people who engage in receptive anal sex and
patients with inflammatory bowel disease.
Symptoms include painful, hardened tissue in the perianal area, discharge of
pus from the rectum, a lump or nodule, tenderness at the edge of the anus,
fever, constipation or pain associated with bowel movements.
· Prompt surgical drainage.
· Medication for pain relief.
· Antibiotics are usually not necessary unless there is associated diabetes or
immunosuppression.


Q:946 . A 65yo lady with T1DM for the last 20y comes with a tender lump near the
anal
opening. She says she also has a fever. What tx should she get?
a. I&D + antibiotics
b. IV antibiotics
c. C&S of aspirate from swelling
d. Painkillers
e. Cautery of swelling (in anal warts and anal fissure)


Clincher(s) Diabetic pt with hx of tender painful lump and fever.
A Perianal abscess
B
C
D
E
KEY A
Additional
Information

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Reference
Dr Khalid/Rabia I&D + antibiotics
see q 245


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional

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Information
Reference
Dr Khalid/Rabia


Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia



Q: 947 An 80yo DM lady presents with redness and swelling over her right foot. It is
tender to touch,
warm and glossy. What are the complications this pt might develop?
a. Meningitis
b. Sepsis
c. Ulcer
d. Gangrene


Clincher(s) DM, swelling features ,tender
A Complication of periorbital cellulitis
B May be late complication
C
D
E
KEY d. Gangrene

Additional Cellulitis to wet gangrene
Information In clinical setting in diabetics it's usually cellulitis then gangrene then sepsis.

Complications of cellulitis
Complications are uncommon but may include:
• Abscess formation.

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• Gangrene.
• Thrombophlebitis/lymphangitis.
• Chronic leg oedema (a late complication which may predispose to
further episodes of infection).
Less common complications (occurring in <1%) include:
• Necrotising fasciitis. Can be differential also caused by streptococcus)
• Osteomyelitis.
• Compartment syndrome.
• Acute glomerulonephritis.
• Endocarditis.
• Septicaemia.
• Streptococcal toxic shock syndrome.
• Meningitis incase of periorbital cellulitis

Flucloxacillin 500 mg four times daily (in adults) is usually given as first-line
Severe cellulitis should be treated with intravenous benzylpenicillin +
flucloxacillin
Reference Patient.info
Dr Khalid/Rabia


Q:968 A 60yo woman presented with radial fx and had a colle’s fx and supracondylar
fx in the past. What inv is req to detect her possibility of having the same prb
later?
a. Dexa scan
b. MRI
c. Nuclear bone scan
d. CT
e. Bone biopsy

.


Clincher(s) Multiple fracture , 60 yr
A , DEXA scan measures the density of the bone and chances of bone fracture
B
C A bone scan is a nuclear imaging test that helps diagnose and track several
types of bone disease and also to look for metastasis
D
E Incase of multiple myeloma
KEY ANS: A
Reason: Increasing Age is associated with osteoporosis and increasing
incidence of fracturesEXA stands for dual-energy X-ray absorptiometry. It is a
scan that uses special X-ray machines to check your bone density
Rx is BISPHOSPHONATES for osteoporosis (first line)

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Additional Fragility fractures due to decrease of bone density
Information
Reference
Dr Khalid/Rabia


Q: 1002 . A 25yo woman has a recent cough, hoarseness and swelling in the neck.
There are several non-tender swellings on both sides of her neck. She has lost
13kgs. She takes recreational drugs (addition- who are immunocompromised).
What is the most probable dx?
a. Thyrotoxicosis
b. Hyperthyroidism
c. Vocal cord nodules
d. Carcinoma bronchus
e. TB


Clincher(s) Non tender swellings , hoarseness cough, addicton
A Thyrotoxicosis due to toxic nodular goitre is more common in people aged
over 60 years.

B Signs and symptoms of hyperthyroidism
C Singer occupation
D Rare at such young age
E non tender matted rubbery lymph nodes.Wt loss ,cough -
KEY ANS: TB

Additional History and clinical picture suggests pulomonary TB spread locally and
Information distantly into lymph nodes.( non tender matted rubbery lymph nodes).Wt loss
cough. Immunocompromised , HIV, drug abusers are at increased risk of
developing

active TB.
Treatment Active Respiratory TB:
2month initial phase: Isoniazid+Rifampicin+erhambutol+pyrazinamide (RIPE)
4month: continuition with Isoniazid+rifamipicin

Meningeal TB treated for 12 months :
2months: Isoniazid+Rifampicin+erhambutol+pyrizinamide
10 months: Isoniazid+rifamipicin
Glucocorticoid given but with gradual withdrawal.

L (latent)TBI: 3month treatment with rifampicin + isoniazid

Miliary TB: disseminated TB – esp to liver: Rx similarly (look up)

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Reference
Dr Khalid/Rabia


Q:1068 A 44yo obese pt with findings: FBS=6 mmol/l, OGTT=10 mmol/l. What is the
most likely dx?
a. Impaired glucose tolerance
b. Diabetes insipidus
c. T1DM
d. T2DM
e. MODY


Clincher(s)
A
B Due to ADH insuffieciency
C
D
E MODY (mature onset diabetic in young)

is a rare form of diabetes which is different from both Type 1 and Type 2
diabetes, and runs strongly in families.

MODY is caused by a mutation (or change) in a single gene. If a parent has this
gene mutation, any child they have, has a 50% chance of inheriting it from
them.

If a child does inherit the mutation they will generally go on to develop MODY
before they’re 25, whatever their weight, lifestyle, ethnic group etc.

The key features of MODY are:

• Being diagnosed with diabetes under the age of 25.

• Having a parent with diabetes, with diabetes in two or more generations.
• Not necessarily needing insulin

KEY Dx is IGT

Additional IGT criteria: fasting <7 and OGTT >7.8 but <11.1
Information
WHO criteria (for DM):
* Symptoms (polydipsia, polyuria, weight loss, lethargy, blurring, genital
thrush)+ fasting >7 and random >11.1
* Raised venous fasting >7 and random >11.1- on 2 separate occasions or
OGTT> 11.1

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* HB 1Ac> 48mmol/L (6.5%)

Reference
Dr Khalid/Rabia


Q:1200 A child has hypothyroidism. What feature is a/w it?
a. Microglossia
b. Prolonged neonatal jaundice
c. Undescended testis
d. Anal tag
e. Left soft palate

Clincher(s) Congenital hypothyroid
A Not present. Its Opposite
B Yes
C Not a feature
D Not present
E Not
KEY b. Prolonged neonatal jaundice
Additional
Information
CONGENITAL HYPOTHYROIDISM

Symptoms
• Feeding difficulties
• Somnolence
• Lethargy
• Low frequency of crying
• Constipation

Signs
• Large fontanelles
• Myxoedema - with coarse features and a large head and oedema of the
genitalia and extremities
• Nasal obstruction
• Macroglossia
• Low temperature (often <35°C) with cold and mottled skin on the
extremities
• Jaundice - prolongation of the physiological jaundice
• Umbilical hernia
• Hypotonia
• Hoarse voice
• Cardiomegaly
• Bradycardia
• Pericardial effusion - usually asymptomatic

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• Failure of fusion of distal femoral epiphyses
• The growing child will have short stature, hypertelorism, depressed
bridge of nose, narrow palpebral fissures and swollen eyelids
• Refractory anaemia

Reference
Dr Khalid/Rabia

Q: 1355 A 66yo man has renal colic. He has also presented with acute onset
pain in his knee in the past.
What is the single most likely cause for renal failure?
a. SLE associated GN
b. Hypercalcemia
c. HTN
d. Hyperuricemia
e. Hyperoxaluria



Clincher(s)
A .(SLE is excluded as it occurs in females 8 times more
than males & affects symmetrically small joints)
B Whereas if hypercalcemia would have been a cause then renal stone
.excessive thirst secondary
to dehydration with generalized bony pain
C
D So, ans would be hyperuricemia. monoarthropathy.. first mtp is characterstic but knee or
any large joint csn be involved

E
KEY D
Additional Gouty arthritis with renal stone
Information

Reference
Dr Khalid/Rabia


Q: 1357 A 26yo man is referred for gastroscopy because of a hx of several
months of dyspepsia. He has
routine bloods checked and is found to have a serum calcium level=3.2mmol/l
with a venous
bicarbonate level of 33mmol/l. Renal and LFT are both mornal. CXR is
normal. What is the most

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likely cause of his hypercalcemia?
a. Melanoma
b. Metastatic malignancy
c. Milk alkali syndrome
d. Primary hyperparathyroidism
e. Sarcoidosis



Clincher(s) High bicarbonate level and hypercalcemia

A
B
C Its milk or calcium alkali syndrome as there is hypercalcemia and metabolic
alkalosis. Milk alkali syndrome (a.k.a calcium alkali syndrome) occurs
commonly in post menopausal woman on calcium supplements or individuals
on antacids (patient has a hx of dyspepsia).They present with hypercalcemia
and metabolic alkalosis

D
E Lung symptoms
KEY C
Additional
Information
Reference
Dr Khalid/Rabia


Q: 1362 A 7yo boy presents with his mother to GP surgery. His mother
describes he had presented this since 3wks ago. He had not experienced any
trauma. No other symptoms a/w the condition. Exam: non tender swollen
ankles bilaterally. There is no rash or lesion. He is otherwise well. Which
single test would be the best as an initial assessment?
a. Plasma electrolytes
b. Albumin
c. Total serum protein
d. Anti-streptolysin



Clincher(s)
A
B Albumin For nephrotic syndrome ..minimal change disease

C
D

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E
KEY B
Additional 24 Hr urinary protein gold standard, if not given then opt for serum albumin..
Information Its nephrotic Albumin For nephrotic syndrome ..minimal change disease
Reference
Dr Khalid/Rabia


Q: 1401 A 22yo Greek man presents with rapid anemia and jaundice following tx of
malaria. He is noted to have Heinx bodies. Choose the single most likely cause
from the
given options?
a. G6PD deficiency
b. Anemia of chronic disease
c. Pernicious anemia
d. IDA
e. Vit B12 deficiency


Clincher(s)
A Answer= Glucose 6 phosphate dehydrogenase deficiency (G6PD). Acute
haemolysis from G6PD deficiency can produce HEINZ BODIES which are
denatured haemoglobin and bite cells. it is precipitated by drugs such as
primaquine (antimalarial),sulfonamides,aspirin.
B anemia of chronic disease: commonest anemia in hospital patients.common
causes include
Chronic infection,Inflammation - including connective tissue
disorders,Neoplasia.

C pernicious Anemia=type of megaloblastic anemia due to impaired absorption
of vitamin b12
deficiency.it is caused by autoimmune atrophic gastritis leading to
acchlorhydria and lack of
intrinsic factor secretion.

D Iron def Anemia=microcytic hypochromic anemia caused by iron deficiency d/t
blood loss,
poor diet,malabsorption etc. blood film shows anisocytosis and poikilocytosis

E vit b12 def= macrocytic anemia caused by vit b12 deficiency d/t dietary
def,pernicious
anemia,ileal resection,gastrectomy.Blood film will show hypersegmented
polymorphs

KEY A
Additional

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Information
Reference
Dr Khalid/Rabia G6PD is x linked chief rbc enzyme defect disorder. it mainly affects males. it is
precipitated by drugs like primaquine,sulfonamides and aspirin.Usually
asymptomatic. In attacks,there is rapid anemia and jaundice.

tests: fbc= anemia
Blood film= heinz bodies
G6PD enzyme activity - is the definitive test (as opposed to the amount of
G6PD protein).

Treatment= Avoidance of the substances that may precipitate hemolysis is
essential. If severe then transfuse. if severe hemolysis, folate supplementation
may be beneficial.


Q: 1405 A pt was admitted with abdominal pain, diarrhea, pigmented palmar creases
and buccal mucosa.
What is the most probable dx?
a. Addison’s disease
b. Cushing syndrome
c. Pheochromocytoma
d. Hyperthyroidism
e. Hypoparathyroidism



Clincher(s)
A answer= addison’s disease. Unexplained abdominal pain and vomiting plus the
pigmented palmar creases and buccal mucosa are its main features pointing
towards the diagnosis.

B cushing syndrome= Cushing's syndrome is caused by prolonged exposure to
elevated levels of either endogenous or exogenous glucocorticoids (mainly
cortisol) main features include: truncal obesity, weight gain,buffalo
hump,moon facies,facial plethora, gonadal dysfunction (hirsutism,irregular
menses,erectile dysfunction) etc pheochromocytoma=catecholamine
producing tumors causing hypertension, episodic headaches.
C
D hyperthyroidism= increased levels of thyroid hormones. features of that.
E hypoparathyroidism= features of hypocalcemia like cramps, paraesthesias,
carpopedal spasm etc
KEY A
Additional
Information
Reference

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Dr Khalid/Rabia
addison’s disease
it is the primary adrenocortical insufficiency. the destruction of adrenal cortex
leads to the
glucocorticoid (cortisol) and mineralocorticoid (aldosterone) deficiency.
80% are due to the autoimmunity in uk. other causes may include TB
(commonest cause worldwide),adrenal metastasis,lymphoma, opportunistic
infections in HIV, adrenal hemorrhage (waterhouse friderichsen syndrome)

features=unexplained abdominal pain or vomiting, diarrhea/constipation,
pigmented palmar creases and buccal mucosa ( acth increases; crossreacts
with melanin receptors),postural hypotension, vitiligo.

Tests:
NA decreased and potassium increased, calcium increased,low glucose,
cortisol reduced. plasma renin and aldosterone levels to assess
mineralocorticoid status

short ACTH stimulation test= may be done to confirm the diagnosis 21
hydroxylase adrenal autoantibodies positive in autoimmune disease in >80%
(Synacthen Test): syn acth given to patient (another name for above)

treatment=
patient education
Hormone replacement: both mineralocorticoid and glucocorticoid should be
replaced

CHAF
CH-Coitsol-hydrocortison
AF- adison diseases- fludrocortisone

glucocorticoid replacement= hydrocortisone is mainstay
mineralocorticoid replacement= fludrocortisone is used

Q:
Venous ulcers are usually painless but there can be mild pain. However,
arterial ulcers are extremely painful especially nocturnal pain. Pt. uk.
Q:2 A 74yo smoker presented to his GP with cough and SOB. Exam revealed pigmentation
of the oral mucosa and also over the palms and soles. Tests show that he is diabetic
and hypokalemic.
What is the most probable dx?
a. Pseudocushing syndrome
b. Conns disease
c. Ectopic ACTH
d. Cushings disease
e. Hypothyroidism

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Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Ans. 1. The key is C. Ectopic ACTH.
Ans. 2. The patient is smoker and probably developed small cell lung cancer
which is working as a tumour producing ectopic ACTH resulting in
pigmentation. Resultant raised cortisol is leading to diabetes and hypokalemia.
the features can be explained by increased levels of ACTH and adrenocortical hormones. So the
question is : ectopic or pituitary ACTH excess? It seems to be from an ectopic source since the
patient is smoker and has SOB and cough ( Lung tumor whether small cell CA bronchus
or carcinoid tumor- both may secrete ectopic ACTH ) . Furthermore , Cushing's
disease is often the result of pituitary ACTH-secreting adenoma that also
causes pressure symptoms like headache and visual disturbances which are
absent in this case.
Ectopic ACTH increase the secretion of aldosterone from adrenal gland and aldosteronism
causes hypernatraemia and hypokalaemia.
Cortisol is a form of stress hormone. So it induces glycogenolysis causing increase in blood
glucose.
No pigmentation in conn
Conns must have hypertension n not necessarily hypokalemia but it presents with signs of
hypokalemia like weakness quadriparsis cramps.
Why not Cushings?
SCLC is a direct cause of ectopic ACTH (statement is clear cut - Smoker). Further ectopic
acth can lead to cushings at later stages but its major cause is use of steroids and
pituitary adenoma while ectopic acth is down the list. And if cushings happen, the major
indicative symptoms are stria, moon face, easily fractured bones, plethora.
Diagnosis : Small Cell Lung CA causing ectopic ACTH.
Main reason : SMOKING for years. At Least 20 so age goes up to 50 to 60. Male.
Symptoms :
Persistent cough, hemoptysis, chest n shoulder pains, SOB, clubbing. +/- pleural effusion,
pneumonia, pins and needles in arm n shoulder sensation.
Invs :
Initial : CXR. Shows shadowing
Confirmatory : CT chest THEN Biopsy thru bronchoscope or transthoracic needle biopsy.
Depends on the location.
Pleural Tap can be done if pleural effusion.
Treatment :
Surgery, radio and chemo.
Prognosis : Good if early diagnosed. Bad if late.


Q:142 142. A 60yo diabetic complains of pain in thigh and gluteal region on walking up the
stairs for the last
6 months. She is a heavy smoker and has ischemic heart disease. What is the most
appropriate
dx?
a. Thromboangitis Obliterans
b. Sciatica
c. DVT

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d. Atherosclerosis
e. Embolus

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia Ans. 1. The key is D. Atherosclerosis.
Ans. 2. i) It is not sciatica as sciatica pain is worse when sitting. There may be
weekness, numbness, difficulty moving the leg or foot. A constant pain on one
side of the rear. A shooting pain that makes it difficult to stand up. ii) It is not
DVT as no swelling, warmth or redness of skin are there iii) It is not
thromboangitis obliterans as pulses are ok, no colour change or reduced hair
growth, no ulceration or gangrene iv) no embolism as no pain (rest pain), no
numbness, no redness or itching or rash, no ulceration of skin.
This patient has intermittent claudication due to atherosclerosis,
Symptoms Cramping pain is felt in the calf, thigh, or buttock after walking for a
given distance (the claudication distance) and relieved by rest. Ulceration,
gangrene, and foot pain at rest—eg burning pain at night relieved by hanging legs
over side of bed—are the cardinal features of critical ischaemia.
Fontaine classification for peripheral arterial disease: 1. Asymptomatic 2.
Intermittent claudication 3.Ischaemic rest pain 4. Ulceration/gangrene (critical
ischaemia)
Signs: Absent femoral, popliteal or foot pulses; cold, white leg(s); atrophic skin;
punched out ulcers (often painful); postural/dependent colour change; a vascular
(Buerger’s) angle of <20° and capillary filling time >15s are found in severe
ischaemia
Imaging: Colour duplex USS is 1st line (non-invasive and readily available). If
considering
intervention then MR/CT angiography
MANAGEMENT: Stop smoking, exercise, treat HTN, antiplatelet (clopidogrel).
Advise exercise until maximum tolerable pain.
Vasoactive drugs may be used. If PAD is advancing consider:
Percutaneous transluminal angioplasty (PTA) is used for disease limited to a
single arterial segment.
Surgical reconstruction: arterial bypass
Amputation. If all fail. Knee should be saved if possible.


Q:170 A 38yo pt presented with tingling, numbness, paraesthesia, resp stridor and
involuntary spasm of the upper extremities. She has undergone surgery for thyroid
carcinoma a week ago. What is the most likely dx?
a. Thyroid storm
b. Hyperparathyroidism

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c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Hypocalcemia

Clincher(s)
A
B
C
D
E
KEY E
Additional
Information

Reference
Dr Khalid/Rabia Ans. 1. The key is E. Hypocalcaemia.
Ans. 2. Hypocalcaemia may be due to accidental parathyroid gland removal
during thyroidectomy.
Ans. 3. Laryngospasm is a feature in hypocalcaemia which may cause stridor.
Thyroid storm causes thyrotoxicosis (inc heart rate, palpitations, weight loss,
tremors, heat intolerance etc) hyperparathyroidism causes hypercalcemia
(bone pains, kidney stones, confusion, psychosis), nerve injuries only explain
the stridor.
Causes of hypocalcemia:
Treatment
• Mild symptoms: give calcium 5mmol/6h PO, with daily plasma Ca2+ levels.
• In chronic kidney disease:May require alfacalcidol
• Severe symptoms: give 10mL of 10% calcium gluconate (2.25mmol) IV over
30min,
and repeat as necessary. If due to respiratory alkalosis, correct the alkalosis


Q:172 A 44yo pt has sudden onset of breathlessness and stridor few minutes after
extubation for thyroidectomy. The pat had longstanding goiter for which he had the

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surgery. What is the most
likely dx?
a. Thyroid storm
b. Hematoma
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Tracheomalacia

Clincher(s)
A
B
C
D
E
KEY E
Additional
Information
Reference
Dr Khalid/Rabia Ans. The key is tracheomalacia


Q:180 A 20yo pop star singer complains of inability to raise the pitch of her voice. She
attributes this to the thyroid surgery she underwent a few months back. What is the
most likely dx?
a. Thyroid storm
b. Bilateral recurrent laryngeal nerve injury
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Thyroid cyst

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia Ans. The key is D. External laryngeal nerve injury.
Complications of thyroid surgery:
1. Bleeding, which may cause tracheal compression.
2. Recurrent laryngeal nerve injury:
· Innervates all of the intrinsic muscles of the larynx, except the cricothyroid
muscle.
· Patients with unilateral vocal fold paralysis present with postoperative
hoarseness. Presentation is often subacute and voice changes may not present for

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days or weeks. Unilateral paralysis may resolve spontaneously.
· Bilateral vocal fold paralysis may occur following a total thyroidectomy and
usually presents immediately after extubation. Both vocal folds remain in the
paramedian position, causing partial airway obstruction.
· Superior (external) laryngeal nerve injury:
o The external branch provides motor function to the cricothyroid muscle.
o Trauma to the nerve results in an inability to lengthen a vocal fold and
thus to create a higher-pitched sound.
o The external branch is probably the most commonly injured nerve in thyroid
surgery.
o Most patients do not notice any change but the problem may be career-ending
for a professional singer.
· Hypoparathyroidism: the resulting hypocalcaemia may be permanent but is
usually transient. The cause of transient hypocalcaemia postoperatively is not
clearly understood.
· Thyrotoxic storm: is an unusual complication of surgery but is potentially lethal.
· Infection: occurs in 1-2% of all cases. Peri-operative antibiotics are not
recommended for thyroid surgery.
· Hypothyroidism.
· Damage to the sympathetic trunk may occur but is rare.


Q:810 A 45yo lady complains of expressable galactorrhea, decreased libido and amenorrhea,
weight
gain and easy fatigue. Her serum prolactin levels are 1100um/l. what is the likely
cause of
hyperprolactinemia?
a. Hypothyroidism
b. Stress
c. Pregnancy
d. Prolactin secreting pituitary tumor
e. PCOS

Clincher(s)
A
B
C
D
E
KEY D
Additional
Information
Reference
Dr Khalid/Rabia

Q:826 826. A young girl who is known to have T1DM presented with drowsiness and deep
breathing. Her
sugar level=20. Her BP=120/80mmHg and her mucous membranes are dry. What
would be the
next appropriate step?

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a. Serum urea
b. Blood culture
c. CT
d. HbA1c
e. ABG

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia


Q:840 A known DM was admitted with sudden LOC. What is the initial inv?
a. CT scan
b. RBS
c. MRI
d. ECG
e. ABG

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia key : B
reason : diabetic pt >>> hypogycemia is common >>> RBS is the
initial inv


Q:843 A pt was admitted with erectile dysfunction, reduced facial hair and galactorrhea.
What is the
most probable dx?
a. Hyperprolactinemia
. Cushi g s s d o e

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c. Pheochromocytoma
d. Hyperthyroidism
e. Hypoparathyroidism

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia key : A
reason : galactorrhea + with erectile dysfunction + reduced facial
hair
hyperprolactinaemia
Presentation
Women:
Common symptoms of are amenorrhoea, oligomenorrhoea and
galactorrhoea.
They may also have infertility, hirsutism and reduced libido.
Men:
The hormonal effects of raised prolactin levels are subtle and
develop slowly.
Endocrine symptoms are reduced libido, reduced beard growth and
erectile dysfunction.
Children:
Growth failure and delayed puberty are possible presentations in
children.
Symptoms due to tumour size (usually macroprolactinomas):
Headache.
Visual disturbances (classically, a bitemporal hemianopia (lateral
visual fields) or upper temporal quadrantanopia).
Cranial nerve palsies.
Symptoms and signs of hypopituitarism.
Rarely, cerebrospinal fluid (CSF) leak or secondary meningitis.
Investigations
Initial investigations
TFTs.
Exclude pregnancy.
Basal serum prolactin:

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If prolactin is mildly elevated (eg 400-1000 mU/L, normal range
<400 mU/L), it should be repeated before referral.
Dynamic prolactin stimulation tests, such as the TRH test, are not
required. Measurement of serum prolactin on three separate
occasions (at least two hours after rising and when the patient is
rested) is sufficient.
A prolactin level >5000 mU/L usually indicates a true prolactinoma.
Further investigations
Visual field testing.
Pituitary imaging (preferably MRI
Assessment of pituitary function


Q:845 A 35yo man with T1DM is dehydrated with BP of 90/50mmHg. What is the single
most
appropriate initial inv?
a. ABG
b. CBC
c. HbA1c
d. LFT
e. Serum Urea

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia key: a
reason : T1DM suspected to have DKA>>> ABG will show acidosis
DKA
DKA is characterised by hyperglycaemia, acidosis, and ketonaemia
DKA is normally seen in type 1 diabetics and may be a presenting
feature of undiagnosed type 1 diabetes, particularly in children.
However DKA may rarely occur in type 2 diabetics
Check capillary blood glucose and blood gases promptly. If these
suggest diabetic ketoacidosis (DKA) then immediately begin
resuscitation and management.
management:
• Immediate resuscitation as required

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• Correct dehydration >>> 0.9% sodium chloride solution is the
recommended fluid of choice
• Insulin therapy >>> A fixed-rate IV insulin infusion calculated on
0.1 units/ per kilogram infusion is recommended.
• Metabolic treatment
• Treat any precipitating illness


Q:846 In OGTT what is the glucose venous plasma level 2h after glucose intake which
indicates impaired glucose tolerance?
a. >11.1mmol/l
b. Between 7.8-11.0mmol/l
c. Between 8.0-10.9mmol/l
d. Between 10.0-11.0mmol/l
e. Between 7.1-11.0mmol/l

Clincher(s)
A
B
C
D
E
KEY ANSWER is B.
Additional
Information
Reference
Dr Khalid/Rabia

Q:1534 A 60yo DM pt presented with easy fatigability, weakness and numbness of hands and
swollen feet. Exam: pedal edema, sensory neuropathy and palpable liver and spleen.
Urine: proteinuria.
US abdomen: enlarged kidney. Renal biopsy: amorphous homogenous substance that
stained
red with congo-red. What is the dx?
a. DM retinopathy
b. Sarcoidosis
c. Wilms tumor
d. Amyloidosis
e. Glycogen storage disease

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Clincher(s)
A
B
C
D
E
KEY D
Additional
Information
Reference
Dr Khalid/Rabia Answer: D (Aggregation of the congo-red dye and binding to amyloid fibrils tends to
red-shift the absorption spectrum, whereas binding to cellulose fibers has the
opposite effect.) Apple-green birefringence of Congo red stained preparates under
polarized light is indicative for the presence of amyloid fibrils. Amyloidosis is a rare
disease that results from accumulation of inappropriately folded proteins. These
misfolded proteins are called amyloids. When proteins that are normally soluble in
water fold to become amyloids, they become insoluble and deposit in organs or
tissues, disrupting normal function. The type of protein that is misfolded and the
organ or tissue in which the misfolded proteins are deposited determines the clinical
manifestations of amyloidosis. Amyloid deposition in the kidneys can cause
nephrotic syndrome, which results from a reduction in the kidney's ability to filter
and hold on to proteins. In AA amyloidosis the kidneys are involved in 91-96% of
people,symptoms ranging from protein in the urine to nephrotic syndrome and rarely
renal insufficiency
Q:1539 A pt was admitted with increased frequency of passing urine, increased thirst,
weakness and
muscle cramps. What is the most probable dx?
a. Co s s d o e
. Cushi g s s d o e
c. Pheochromocytoma
d. Hyperthyroidism
e. Hypoparathyroidism

Clincher(s)
A
B
C
D
E
KEY Answer: D (Aggregation of the congo-red dye and binding to amyloid fibrils tends to
red-shift the absorption spectrum, whereas binding to cellulose fibers has the
opposite effect.) Apple-green birefringence of Congo red stained preparates under
polarized light is indicative for the presence of amyloid fibrils. Amyloidosis is a rare
disease that results from accumulation of inappropriately folded proteins. These
misfolded proteins are called amyloids. When proteins that are normally soluble in
water fold to become amyloids, they become insoluble and deposit in organs or
tissues, disrupting normal function. The type of protein that is misfolded and the
organ or tissue in which the misfolded proteins are deposited determines the clinical

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manifestations of amyloidosis. Amyloid deposition in the kidneys can cause
nephrotic syndrome, which results from a reduction in the kidney's ability to filter
and hold on to proteins. In AA amyloidosis the kidneys are involved in 91-96% of
people,symptoms ranging from protein in the urine to nephrotic syndrome and rarely
renal insufficiency.
Additional
Information
Reference
Dr Khalid/Rabia
Q:1624 1624. A 15yo man presents with bitemporal hemianopia and spade-like hands. What
is the definite
test to confirm the dx?
a. Early morning growth hormone
b. Insulin tolerance test
c. OGTT with growth hormone measurements
d. Random insulin-like growth factor (IGF-1)
e. Short ACTH test

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Key: OGTT with growth hormone measurements (C)
Reason: The bitemporal hemianopia and spade-like hands point towards this
being acromegaly. The best initial test is insulin like growth factors but the
definitive test that confirms the diagnosis is OGTT with serial growth hormone
measurements. Early morning growth hormone would be raised anyway, it is
released in a pulsatile manner, Short ACTH is used for Cushing’s disease and
Insulin tolerance test is not used for growth hormone or acromegaly
assessment.
Discussion:
How is acromegaly diagnosed?
* A blood test can measure the level of growth hormone. However, a single test
is not reliable. This is because the levels of growth hormone in the body
fluctuate a lot throughout the day in all people. * The diagnosis of acromegaly
is made by a glucose tolerance test. In this test you drink a sugar drink
containing 75 grams of glucose. You then have a series of blood tests over two
hours. The glucose should lower the blood level of growth hormone. However,
if you have acromegaly, the growth hormone level remains high.
* A blood test to measure the level of IGF-1 (see above) may be measured if
acromegaly is suspected. This may also be used as an index of disease
activity to assess how well treatment is working. * A magnetic resonance
imaging (MRI) scan can show the size of any tumour.
* Eye and visual tests can assess if the tumour is pressing on the optic nerve.

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* If you are confirmed as having acromegaly, other tests will be needed to see
if the tumour is causing a lack or excess of other hormones made by the
pituitary. * Other tests may include chest X-ray, electrocardiogram (ECG) and
X-rays of some of your joints.
What are the treatments for acromegaly?
The aim of treatment is to reduce the level of growth hormone in the blood to
normal, and to reduce the size of an enlarged tumour. Many of the symptoms
and features of acromegaly will reverse or improve with successful treatment
(apart from any fixed extra bone growth that had occurred).
Surgical treatment
The most common treatment is to remove the adenoma by surgery. This is
done using very fine instruments. There are two different ways to operate on
the pituitary gland:
o The first method is known as endonasal trans-sphenoidal surgery. This
involves the surgeon reaching your pituitary gland through a small cut (incision)
in wall of one of your nostrils. In the other way, the surgeon approaches the
pituitary gland through a small incision behind your upper lip, just above your
front teeth. The instruments are passed through the base of your skull - the
sphenoid bone. The aim is to remove the adenoma, but to leave the rest of the
pituitary gland intact.
o The operation is successful, with no further treatment needed, in around 9 out of 10
cases with smaller tumours. The operation is l
Q:1657 1657. You suspect Cushing's disease in a 50yo woman who has attended clinic with
glycosuria, HTN
and a suggestive body habitus. Initial inv point you towards a dx of Cushing's disease.
Which of
the following findings would be against this dx?
a. A normal 8am cortisol
b. Failure to suppress morning cortisol with dexamethasone
c. HTN requiring >2 antihypertensive agents
d. Impaired growth hormone response to glucose loading
e. Unilateral adrenal enlargement

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Key: OGTT with growth hormone measurements (C)
Reason: The bitemporal hemianopia and spade-like hands point towards this
being acromegaly. The best initial test is insulin like growth factors but the
definitive test that confirms the diagnosis is OGTT with serial growth hormone
measurements. Early morning growth hormone would be raised anyway, it is
released in a pulsatile manner, Short ACTH is used for Cushing’s disease and
Insulin tolerance test is not used for growth hormone or acromegaly
assessment.

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Discussion:
How is acromegaly diagnosed?
* A blood test can measure the level of growth hormone. However, a single test
is not reliable. This is because the levels of growth hormone in the body
fluctuate a lot throughout the day in all people. * The diagnosis of acromegaly
is made by a glucose tolerance test. In this test you drink a sugar drink
containing 75 grams of glucose. You then have a series of blood tests over two
hours. The glucose should lower the blood level of growth hormone. However,
if you have acromegaly, the growth hormone level remains high.
* A blood test to measure the level of IGF-1 (see above) may be measured if
acromegaly is suspected. This may also be used as an index of disease
activity to assess how well treatment is working. * A magnetic resonance
imaging (MRI) scan can show the size of any tumour.
* Eye and visual tests can assess if the tumour is pressing on the optic nerve.
* If you are confirmed as having acromegaly, other tests will be needed to see
if the tumour is causing a lack or excess of other hormones made by the
pituitary. * Other tests may include chest X-ray, electrocardiogram (ECG) and
X-rays of some of your joints.
What are the treatments for acromegaly?
The aim of treatment is to reduce the level of growth hormone in the blood to
normal, and to reduce the size of an enlarged tumour. Many of the symptoms
and features of acromegaly will reverse or improve with successful treatment
(apart from any fixed extra bone growth that had occurred).
Surgical treatment
The most common treatment is to remove the adenoma by surgery. This is
done using very fine instruments. There are two different ways to operate on
the pituitary gland:
o The first method is known as endonasal trans-sphenoidal surgery. This
involves the surgeon reaching your pituitary gland through a small cut (incision)
in wall of one of your nostrils. In the other way, the surgeon approaches the
pituitary gland through a small incision behind your upper lip, just above your
front teeth. The instruments are passed through the base of your skull - the
sphenoid bone. The aim is to remove the adenoma, but to leave the rest of the
pituitary gland intact.
o The operation is successful, with no further treatment needed, in around 9 out of 10
cases with smaller tumours. The operation is l
Q:1691 1691. A 29yo Afro-Caribbean man presents with a non-productive cough mild aches in
the ankles. The
symptoms have been present for 2m. His ESR is elevated. Ca: 2.69 mmol/l; PO43-:
1.20 mmol/l;
ALP: 80 iu/L. Serum 25(OH) D: 180 nmol/l.
Normal values for Calcium: 2.12-2.65mmol/l; Phosphate: 0.8-1.45mmol/l; ALP 30-
300iu/L;
Serum 25(OH) D: 20-105nmol/l; Urea: 2.5-6.7mmol/l; Creatinine: 70-120μmol/l
a. Osteoporosis
b. Thiazide diuretics
c. Skeletal metastases
d. Primary hyperparathyroidism
e. Hypoparathyroidism
f. Osteomalacia
g. Multiple myeloma
h. Paget's disease of bone
i. Sarcoidosis

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j. Hyperthyroidism

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia
Q:476 476. A 28yo female presents with 1 wk hx of jaundice and 2d hx of altered sleep
pattern and moods.
She was dx with hypothyroidism for which she is receiving thyroxine. TFT showed
increased TSH.
PT=70s. What is the most probable dx?
a. Acute on chronic liver failure
b. Hyper-acute liver failure
c. Autoimmune hepatitis
d. Acute liver failure
e. Drug induced hepatitis

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia KEY- C
Autoimmune hepatitis may present as acute hepatitis, chronic
hepatitis, or well-established cirrhosis. Autoimmune hepatitis rarely
presents as fulminant hepatic failure. One third may present as acute
hepatitis marked by fever, hepatic tenderness and jaundice. Non
specific features are anorexia, weight loss and behavioural change
(here altered sleep pattern and moods). There may be coagulopathy
(here PT=70s.) leading to epistaxis, gum bleeding etc. Presence of
other autoimmune disease like hypothyroidism supports the
diagnosis of autoimmune hepatitis.
Q:493 493. An 8yo boy is clinically obese. As a baby he was floppy and difficult to feed. He
now has learning

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difficulties and is constantly eating despite measures by his parents to hide food out
of reach.
What is the most probable dx?
a. Cushi g s s d o e
b. Congenital hypothyroidism
c. Prader Willi syndrome
d. Lawrence moon biedel syndrome
e. Do s s d o e

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia KEY- C
Prader Willi syndrome- congenital disorder caused by defect in gene
on chromosome 15. Characterized by hypotonia at birth, feeding
difficulties, poor growth and delayed development. At the beginning
of childhood, they present with obsessive eating and obesity,
learning difficulties, behavioural
problems and compulsive behavior such as picking on skin.
Distinctive facial features like triangular mouth, unusually fair skin
and light-coloured hair, almond shaped eyes and short forehead.
Q:506 506. A 10yo boy is clinically obese and the shortest in his class. He had a renal
transplant last year
and his mother is worried that he is being bullied. What is the most probable dx?
a. Cushi g s s d o e
b. Congenital hypothyroidism
. Pseudo ushi g s syndrome
d. Lawrence moon biedel syndrome
e. Do s s d o e

Clincher(s)
A
B
C
D
E
KEY
Additional
Information

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Reference
Dr Khalid/Rabia a. Cushing’s syndrome
he's on steroids post-renal transplant, Oral steroids is the chief cause of Cushing's syndrome
(OHCM, 8th, page 124).
Laurance-moon synd. Night blindness due to retinitis pigmentosa, polydactyly are important
features (OHCS/8th/648). With no emphasis on more common features, Oral-steroid induced
(post renal transplant) Cushing makes more sense.
Congenital hypothyroidism Feeding difficulties, Somnolence, Lethargy, Low frequency of
crying, Constipation
Down’s syndrome he is clinically obese not conganital case,down syndrome has cardaic
problem and characteristic facial feature and mentalyy retarded so it cant be option,these
features are same for lawrence moon but ptnt are mentally retarded whereas kid is studying in
normal school rather than special one
Pseudocushing’s syndromeit is mainly an idiopathic condition.Some frequently occurring illnesses can
induce a phenotype that largely overlaps with Cushing syndrome and is accompanied by hypercorticolism
Q:1175 1175. A 72yo presents with polyuria and polydipsia. The fasting blood sugar is 8 and
10mmol/l.
BP=130/80mmHg and the level of cholesterol=5.7mmol/l. There is microalbuminuria.
What is
the single most appropriate next management?
a. ACEi and sulfonylurea
b. Statin and biguanide
c. Statin and glitazone
d. Insulin and ACEi
e. Statin and ACEi

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia ACEI should be considered in diabetic patients , especially in those with renal
complications. A statin is considered in all diabetic patients above the age of 40
years ( BNF ) . An oral hypoglycemic drug does not seem to be needed since
the sugar levels aren't that high and may respond to lifestyle and dietary
modifications alone.
when microalbuminuria is present , the target BP is 125/75. therefore , ACE-i
should be given. Cholesterol is also raised , so statins
Diabetic pt, target BP <=130/80.
Diabetic pt plus microalbuminaria , target BP <=125/75.
1st line in diabetes RX is lifestyle modification than biguanides (if not responding to
1st)
Q:1176 1176. A 49yo woman presents to the OPD. Her oral glucose test after 2h of glucose
intake vs plasma
level in 2 different tests are 6mmol/l and 10mmol/l. This situation can be categoraized
as
a. Impaired glucose tolerance

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b. Impaired fasting glucose
c. T1DM
d. T2DM
e. Metabolic syndrome

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia a. Impaired glucose tolerance
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies
impaired fasting glucose (IFG)
Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less
than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but
less than 11.1 mmol/l
Diabetes UK suggests:
· 'People with IFG should then be offered an oral glucose tolerance test to rule
out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l
indicat

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