ENDOCRINE AND METABOLIC DISEASES

1.
a F Dopamine inhibits prolactin release
b F Somatostatin inhibits growth hormone release
c T In vivo significance of effect on
prolactin is uncertain
d T Gonadal steroids and inhibin modify GnRH effects
e T Arginine vasopressin also effects ACTH release

2.
a T Prolactin-secreting turnours are the most common
b T May be visualised on CT scanning
c F Usually basophil microadenoma
d F Usually acidophil macroadenoma
e T Other visual field losses may occur

3.
a T Perhaps with prognathism and skull growth
b T Or impaired glucose tolerance
c T And perhaps hepatornegaly
d F Growth hormone levels fail to
suppress
e T The skin is thickened with increased sebum production

4.
a F Not usually apparent on plain films
b T Impotence in men
c T Impaired glucose tolerance
d F Plasma cortisol is not suppressed
e F Hypertension and hypokalaernia

5.
a T Physiological pregnancy
b T And metoclopramide, methyldopa
c T TRH is elevated
dT
eT

206
6.
a F Usually isolated GHRH secretory failure
b F Affects the minority
cT
d T As an isolated abnormality With consequent short stature
e F Puberty not affected

7.
a F May cause gigantism
b T And other chromosomal abnormalities
c T And malnutrition
d T Usually with obesity
e F Primary hypothyroidism

8.
a T Pituitary necrosis (Sheehan's syndrome
b F Usually microadenoma
c T Usually macroadenoma
d T Rare
e T Acquired hypothalamic damage

9.
a F Aldosterone secretion is maintained
b F There is secondary adrenal insuff iciency
c T Impaired LH then FSH secretion
d T There is increased insulin sensitivity
e T With hypoglycaernia and hypothermia

10.
AF Severe hypernatraernia only when water access denied
BT Glucocorticoid insufficiency may mask diabetes insipidus
CT Or secondary to pituitary turnours or sarcoid
DF Carbamazepine stimulates ADH release
ET An effect of long-term overhydration in psychogenic polydipsia
 11.
AT
B T Used in manic depressive states Rarely encountered in clinical practice
C T Also inherited in cystinosis
D F Chlorpropamide increases renal sensitivity to vasopressin
E F Hypokalaemia and hypercalcaernia

12.
A T And encephalitis
B T Even apparently minor injury
C T And pulmonary tuberculosis
D T And pancreas, ureter, bladder, prostatic and other malignancies
E T As well as carbamazepine,chlorpropamide and others

13.
A T Thyroglobulin is synthesized within thyroid cells
B F T4 should be regarded as a prohormone
C F Bound to thyroxine-binding globulin and also to pre-albumin
D T T4 is deiodinated in liver, muscle and kidney
E T Production of reverse T3 may increase

14.
A T With secondary hypothyroidism
B F TSH would be elevated
C T Free T4 is normal
D T And other acute illness
E F Total T4 increased

15.
A F May occur in acute non-thyroidal illness
B T Suggests primary hyperthyroidism
C F Suggests secondary hypothyroidism
D T Suggests autoimmune primary hypothyroidism
E F May be seen in pregnancy

16.
A T In around 75% of cases
B T 15% multinodular, 5% single nodule
C T May also cause hypothyroidism
D T Goitre is therefore usually present
E T And HLA B8 and DR2
17.
A T Or persisting resting sinus
tachycardia
B T Appetite is maintained
C F Muscular weakness may occur
D T Occasionally with ophthalmoplegia
E F Insulin requirements may increase

18.
A F Controls ventricular response rate
B F Inhibits the iodination of tyrosine
C F TSH measurement alone should not guide therapy
D F But titres correlate poorly with disease activity
E T Especially patients with large goitres

19.
A F Suggests treatment - induced hypothyroidism
B T 40% in first year - long-term followup necessary
C F Relapse is uncommon
D T In 75% if given a standard dose
E F In 25% if given a standard dose

20.
A F Radioiodine is better avoided in patients < 40 years of age
B F Potassium perchlorate is now avoided - high toxicity
C T Beta blockers are useful for symptomatic treatment
D T Particularly if a recurrent episode
E T Steroids are used in thyroid crisis and severe eye complications

21.
a T 15% are rendered permanently
hypothyroid at 1 year
b T producing dysphonia
c T 5-10% develop post-operative
hypocalcaemia
d T 5% at 1 year
e F No known association

22.
A F Excessive lacrimation and conjunctivitis are more common
B F Ophthalmopathy may precede hyperthyroidism or even follow treatment
C F No such test available unfortunately
D T Steroids or surgery may be needed in other cases
E T Therefore avoid over-treatment of
hyperthyroidism if possible

23.
A T Both however are non-specif ic
B T And infertility and impotence
C T Perhaps due to oedema of the middle ear
D T Rarely alopecia, vitiligo and dry hair
E F Reflexes preserved with delayed relaxation

24.
A F Free T3 is an unreliable discriminant
B T Rarely causing galactorrhoea
C T Producing hyponatraemia
D F Serum lactate dehydrogenase and creatine kinase may be elevated
E T And serum triglyceride levels

25.
A F There may be constipation
B T But puberty is usually delayed
C T May present with short stature
D T Epiphyseal closure is delayed
E T But a rare occurrence

26.
A T Generalised organornegaly can occur
B T Usually with hypothyroidism
C T Often associated with hypothyroidism
D T Usually no treatment required
E T With nerve deafness; autosomal recessive

208

27.
A F Goitre may occur at any age
B T The most common cause of goitrous hypothyroidism
C T Typically deficiency of intrathyroidal peroxidase
D F Should suppress the serum TSH
E F May be seen in Hashimoto's disease
28.
A* F The thyroid is typically painful
B T Virus-induced thyroid inflammation
C F But biochemical evidence of
hyperthyroidism is common
D T Antibodies in low titre transiently
E F Transient hypothyroidism with
thyroidal recovery usually

29.
A F May cause painful thyroiditis with
transient hypothyroidism
B T Hypothyroidism if iodine deficiency is severe
C F No association
D T Secondary hypothyroldism
E T E.g. cassava root

30.
A F 'Hot' nodules are almost always
benign
B F Radiotherapy provides brief -
symptomatic relief only
C F Total thyroidectomy, radioiodine and ,long-term thyroxine
D T Papillary turnours are the most
common cell type
E F Rare despite high calcitonin levels; carcinoid syndrome can occur

31.
A F 40% of calcium is protein-bound; normal after correction for serum albumin
B F But metabolic alkalosis increases the level of ionised calcium
C T Due to bone metastases (often
microscopic)
D F Decreases serum calcium levels
E T Increases vitamin D level production with low PTH levels
 129

32.
A T But 50% are asymptomatic
B F Solitary parathyroid adenoma in 90%
C F A relatively late feature
D T And peptic ulceration and myopathy
E T With characteristic polyuria

33.
A F Phosphate is usually low
B F Increased 1,25 D levels
C T Predisposing to stone formation
D T Indicating osteoblastic activity
E T Chloride is usually elevated

34.
A F Feature of idiopathic hypoparathyroidism
B T Secondary to hyperphosphataernia, hypocalcaemia and low vitamin D levels
C F Diffuse hypertrophy of small glands
D* T Tertiary hyperparathyroidism
E T Failure of vitamin D absorption

35.
0 F Autosomal dominant
0T
0 F Type 11
(D F Type 11
0T

36.
A T Often via production of osteoclast activating factors
B T Undetectable using standard PTH assays
C T Increased vitamin D level production with low PTH levels
D F Hyperthyroidism is a rare cause
E T Increased vitamin D level production with low PTH levels

37.
A T Features of tetany
B T And mouth and oesophagus
C F Features of hypercalcaernia
D T Basal ganglia calcification is typical
E T In prolonged hypocalcaemia

38.
A T Adrenal, thyroid and ovary
B T Presents in infancy
C T Occurs in 1%
D F Calcitonin elevation occasionally causes hypocalcaernia
EF

39.
A T Producing tissue resistance to PTH
B F PTH concentrations rise cf. true hypoparathyroidism
C F Serum phosphate is high
D T And occasionally mental retardation
E F Alfacalcidol treatment

40.
A F Alkalosis reduces the ionised calcium
B F Alkalosis reduces the ionised calcium
C F Alkalosis reduces the ionised calcium
D T Due to sequestration in areas of pancreatic and fat necrosis
E T Vitamin D malabsorption

41.
A T Usually 20 ml of a 10% solution
B F Rendered ineffective by antibody formation
C F Calcitonin may worsen hypocalcaernia
D T But serum calcium must be monitored
E F But indicated in tetany due to hyperventilation alkalosis

42.
A F Principally under control of angiotensin 11
B T In the zona reticularis and zona fasciculata respectively
C F Cortisol levels fall to a nadir at around midnight
D F Hypoglycaemia stimulates cortisol release
E T Anti-insulin effects

43.
A T 'Pseudo-Cushing's' syndrome due to stress responses
B F Pituitary microadenoma or hyperplasia
C F Weight loss, pigmentation and metabolic alkalosis
D T Non-ACTH-dependent Cushing's
E F Mineralocorticoid effects

44.
A T Protein catabolism in bone
B F Hypertension may occur
C T Impotence in men
D T Muscle protein catabolism
E F Impaired glucose tolerance

45.
A F Diurnal pattern of secretion is lost
B F Plasma cortisol fails to suppress with dexamethasone
C T Sometimes used as a screening test
D T Particularly in virilising turnours
E F ACTH is undetectable at all times

46.
A T Decreases mucosal resistance
B T Increased renal sodium reabsorption
C T Particularly likely to affect the femoral heads
D F Sometimes used to treat severe
pseudo-gout
E T Typical; causes day-night reversal of biorhythms

47.
A F Cf. oedema in patients with secondary hyperalclosteronism
B T Rarely hypokalaernic paralysis
C T Hypertension and hypokalaernia are characteristic
D F NIDDM is however associated with primary hypoadrenalism
E F Associated with renin suppression

48.
AT Rare cause
BT Commonest cause
CT Rare
DF Both may cause hypercalcaernia
ET Now a rare cause

49.
A T All features of glucocorticoid insufficiency
B F Only new scars become pigmented
C T Vitiligo is seen in 10-20%
D F Increased insulin sensitivity with
hypoglycaemia
E T Loss of adrenal androgen

50.
A T Especially if caused by an expanding pituitary lesion
B T ACTH stimulation cannot distinguish primary from secondary failure
C F ACTH levels are not elevated and no autoimmune association
D F No mineralocorticoid deficiency
E F Replacement therapy should mimic the diurnal rhythm

51.
A T Cortisol acetate requires initial hepatic metabolism
B F Mineralocorticoid is invariably required
C F Patients must increase dose with
intercurrent illness
D T Pay attention to the underlying
precipitant
E F 30-40 mg per day usually

52.
A T With defective cortisol production; 20% are due to 11 -hydroxylase
deficiency
B T But mineralocorticoids preserved in two thirds
C T Unlike females, appear normally virilised and recognition can be delayed
D T High levels of androgens
E T Increased ACTH secretion
53.
AF Measurement of plasma ACTH and an ACTH stimulation test often suff ice
BT Or if severe hypoglycaemic symptoms develop
CT Serious risk of hypoglycaemiainduced complications
DT Plasma cortisol at 0800 hrs < 180 nmol/L
EF Test of hypothalamic-pituitary-ad renal axis

54.
A F Noradrenaline is a precursor of adrenaline
B T Catecholamine secretion
C F 90% are benign
D T Occurs in MEN type 11 syndrome
E F Symptoms worsen due to unopposed alpha-adrenoceptor activity

55.
A T Hype rp rolacti naem ia and testicular dysfunction
B T Psychogenic impotence
C T Involving internal pudendal artery
D T Vascular disease and autonomic neuropathy
E T Spinal cord demyelination

56.
A T E.g. following severe orchitis
B F Malclescencled testes in an adult should be removed
C T Antisperm antibodies may subsequently destroy sperm
D F No treatment is widely effective
E F Suggests pituitary/hypothalamic cause

57.
A F Serum LH is elevated
B F Serum FSH is elevated
C T Associated with anosmia
D F Testicular damage - hypergonadotrophic
E F Altered metabolism of testosterone - hype rgonadotrop h ic

58.
A F Adrenal androgen production is spared
B F Height is excessive due to failure of epiphyseal fusion
C T Testicular atrophy in particular
D T Androgen deficiency
E T Testosterone withdrawal

59.
A T Usually 47,XXY chromosomal composition
B T Usually 45,X
C T May present with secondary amenorrhoea or premature menopause
D T Affects 15% of males with leprosy
E T May also be associated with reduced serum gonadotrophins

60.
A T Chromosomal abnormalities are rare
B T Occurs in the minority
C F Sterility follows if bilateral
D T Secondary sexual characteristics are preserved
E F Testicular descent ensues in 40%

61.
A F May cause dysmenorrhoea
B T Elevated adrenal androgens
C T Distinctive morphological features
D T Or other severe systemic disease
E T Or other hypothalamic or pituitary problem

62.
A T Suppression of GnRH
B T Failure of gonadotrophin secretion
C T Impotence in men
D T Or other severe systemic disease
E T Polycystic ovary disease

63.
A F Gonadotrophins elevated
B F Features of androgen excess
C F Osteoporosis develops prematurely
D T Due to oestrogen deficiency
E F Normal menopause occurs at this age

64.
A T But 50% if NIDDM undetected
B F Converse applies particularly if obese
C F Inheritance is polygenic
D T 70% aged over 50 years in UK
E F 90% of islet cell mass must be destroyed

65.
A T Patchy distribution in pancreas
B T Cross- reactivity of antibodies to bovine serum albumin
C T And anti-insulin antibodies
D T Schmidt's syndrome
E T Coded on the short arm of
chromosome 6

66.
A T Hypokalaernic alkalosis impairs
insulin secretion
B T Pancreatic fibrosis
C T Conn's syndrome produces an
hypokalaernic alkalosis
D T Islet cell destruction
E T Excessive counter-regulatory
hormones

67.
A F In contrast to IDDM
B T Cf. 60% concordance in monozygotic twins with IDDM
C F Variable insulin resistance
D T Especially if combined with
underactivity
E T In contrast to IDDM

68.
A T Due to osmotic diuresis
BF Catabolism, including glycogenolysis, is increased
C F Increased lipolysis and enhanced
ketogenesis
D T Primarily hepatic
E T Intracellular to extracellular fluid shift

69.
A T And increased plasma osmolality
B T Compensatory respiratory alkalosis
C T Thirst and hence intake may be
impaired
D T More profound ketogenesis occurs in IDDM
E F Insulin deficiency increases their
production only

70.
A F Too insensitive to detect all cases
B F Renal threshold may be high
C T But it should never be assumed to be so
D F 10-20% have serious vascular
disease
E T Red cells contain less glucose

71.
A T IDDM or NIDDM may subsequently
develop
B T Predisposition to arterial disease
remains
C T Or thiazide diuretic therapy
D F Risk of IDDM > 6%
E F Risk of IDDM 36%

72.
A T Or plasma glucose> 11. 1 mmol/L
B T Or plasma glucose > 7.8 mmol/L
C F Prolonged restriction impairs glucose tolerance
D T WHO standard test (11985)
E F High levels occur within 120 minutes if gastric emptying is rapid

73.
A F Plasma values are higher than whole blood
B T But specific type of stick used should be checked
C F Positive if > 0.5-1.0 mmol/L
D T Normally distributed about this mean
E F Unrelated to the later development of NIDDM
74.
AT Catabolism and osmotic diuresis
BT Predisposition to infection
CT Particularly in ketosis
DT Small vessel disease and neuropathy
ET Often detected on routine urine testing

75.
A F 50% of new diabetics can be
controlled on diet alone
B T Higher than that in average UK diet
C F Consume within diet guidelines
D T UK national diet tends to higher proportion of fat
E F Severe calorie restriction cannot be sustained for long

76.
A F Combined treatment may limit weight gain
B F Insulin secretion is stimulated
C F Such an action would produce insulin resistance
D T Thus limiting hyperglycaernia
E T Disulfiram-like reaction

77.
A T Onset of effect = 30 minutes after injection
B T Variably delayed onset of action
C F Often relative insulin resistance
D T But varies in other countries
E F Conversion to human insulin may cause hypoglycaernia

78.
A T Causes and effects of hypoglycaemia should be familiar
to patients
B T Insulin resistance may decline
C F Unlikely to achieve good glycaemic control
D F Check every 2-3 months
E F Patients need to check blood glucose levels regularly

79.
A T But 50% of long term IDDM patients have no symptoms
B T Sympathetic nervous system
activation
C T Neuroglycopenia
D F But plasma glucose may not parallel CSF glucose levels
E T Nocturnal hypoglycaemia may be difficult to recognise

80.
A T 25 g of glucose
B T Because glucagon increases insulin secretion
C T Hypoglycaemia does not occur with biguanides
D F Can recur following initial treatment
E F Long-acting hypoglycaemics cause prolonged
hypoglycaemia

81.
A F Volume depletion in ketoacidosis
B T Diminished in ketoacidosis
C F Suggests metabolic acidosis
D T Dehydration in ketoacidosis
E F An insensitive indicator of
ketoacidosis

82.
A T Due to ketoacidosis
B T Due to dehydration
C F Skin is typically dry
D T Due to ketosis and dehydration
E F Suggests severe hypoglycaernia

83.
A T 50% intracellular + 50% extracellular
B T Chloride deficit similar
C F Picture should be that of an acute metabolic not
respiratory acidosis
D F Typically normal or high
E T Even in absence of infection
84.
a F Best replaced by 5-10% dextrose when blood glucose is
near normal
b F Give none if K' > 5.5 mmol/L
c T Or in severe acidosis - pH < 7.0
d F Dextrose is used to correct ICF depletion and if blood
glucose < 15 mmol/L
e T Central venous pressure monitoring may be necessary

85.
a F Photocoagulation is indicated
b F Often the first sign of retinopathy
detectable by ophthalmoscopy
c F Regular examination is mandatory
d F Suggests glomerular dysfunction and is a sensitive
indicator of microangiopathy
e T Due to cardiac autonomic neuropathy

86.
a T Due to intrauterine death, prematurity and congenital
malformation
b F Typically larger than expected
c F Defer delivery to 38-39 weeks or later if possible
d F Insulin is necessary to achieve optimal control
e F Requirements increase in second trimester

87.
a T Minimise risk of intraoperative
hypoglycaemia
b F Usual s.c. insulin should be
substituted with GKI infusion
c T Observation alone in minor surgery
d F Often higher
e T With 2-4 hourly BM strip measurement

88.
a T Risk of pancreatitis, no atherogenic risk
b T Triglycerides variably abnormal in all except type I I a
c T May be slightly elevated in type V
d T And premature coronary atherosclerosis
e T Rare in comparison to type I I
89.
aT And aim for weight reduction to body mass index < 25
bF Particularly in patients with coronary artery disease
cT Especially if refractory to dietary measures
dF Suggests better risk profile
eF Statins have such an effect

90.
a T By definition, blood glucose < 2.5mmol/L
b T Often overlooked as cause of cerebral symptoms
c F An overnight or 12-hour fast is usually suff icient
d T Early dumping is due to the release of vasoactive
amines/hormones
e T Symptoms then relieved by eating

91.
a T Rate-limiting step in biosynthesis of haem
b T Porphobilinogen accumulates
c F Typical of acute porphyria
d F Typical of the non-acute porphyrias
e T Both are hepatic porphyrias

92.
a F Decreased PD enzyme activity levels
b T Until precipitated by drugs or alcohol in some
c T Pain may mimic acute abdomen
d T Marked systemic upset
e F Barbiturates and oral contraceptives typically induce
exacerbations