MRCP Part 1 Endocrinology best of five

MRCP Part Endocrinology Best of five Dr Hakim Assalahi 2014 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi MRCP Part Endocrinology Best of five EDITED BY Dr Hakim Assalahi 1st Edition 2014 https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Copyright © 2014 Contrary to Copyright Act of 1976, any part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the permission of the publisher.) This is what we learned in our religion that does not have a monopoly of science.( For more updated information and effective participation, you can join the group here: https://www.facebook.com/groups/199519093570328/ Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi PREFACE This is the first edition of MRCP Part Endocrinology best of five that I have had the honor of working on MRCP Part Endocrinology best of five is a part of a huge work include all sections of internal medicine Endocrinology, Gastroenterology, Cardiology, Infectious Diseases and GUM, Respiratory medicine, Rheumatology, Dermatology, Nephrology, Psychiatry, Ophthalmology, Neurology, Clinical hematology, Clinical Pharmacology, Therapeutics and Toxicology and oncology, Geriatric medicine and Clinical sciences witch include Cell, molecular and membrane biology, Clinical anatomy, Clinical biochemistry and metabolism, Clinical physiology, Genetics, Statistics, epidemiology and evidence-based medicine and Immunology The care of patients is a privilege As physicians, we owe it to our patients to be intelligent, contemporary, and curious Continuing education takes many forms; many of us enjoy the intellectual stimulation and active learning challenge of the question-answer format It is in that spirit that I offer the 1st edition of the MRCP Part Endocrinology best of five to students, house staff, and practitioners I hope that from it you will learn, read, investigate, and question The questions and answers are particularly conducive to collaboration and discussion with colleagues This edition contains over 183 questions that, whenever possible, utilize realistic patient scenarios including radiographic or pathologic images Similarly, the answers attempt to explain the correct or best choice “We are here to add what we can to life, not to get what we can from life.” We hope this addition to your life stimulates your mind, challenges your thinking, and translates to your patients I would like to thank all my friends and members of my group that participate effectively in producing this work It is truly inspirational to remind ourselves why we love medicine broadly, and internal medicine specifically Of course, none of this would be possible without the loving support of our families, for which we are truly thankful They were patient and encouraging as we transformed (often not quietly) a mountain of page proofs into this book https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology Which of the following features can be seen in general in thyrotoxicosis and is not specific to Graves Disease? A B C D E Exophthalmos Ophthalmoplegia Lid Lag Thyroid Acropachy Pretibial Myxoedema Lid lag can occur in any cause of hyperthyroidism The rest of the options are only seen in Graves Disease https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology A 30 year old female who o0ne year ago gave birth and suffered from post partum haemorrhage presents to her GP with fatigue She has also noticed her periods have not returned, constipation, change in her hair and nails She also feels dizzy when she is standing On examination she looks pale, there is a postural drop in blood pressure and she has slowed tendon reflexes Bloods reveal a glucose of 3.9 and a normochromic normocytic anaemia What is the most likely diagnosis? A B C D E Cushings syndrome Addisons disease Hyperthyroidism Hypopituitarism Hypothyroidism This patient is showing features of FHS/LH deficiency with amenorrhoea as after one year postpartum you would expect periods to have returned She is also showing features of hypothyroidism (hail and nail changes, slowed reflexes) and of ACTH deficiency (pallor (ACTH stimulates melanocytes) and postural drop ) The history of postpartum haemorrhage is significant as this may have lead to Sheehans syndrome and thus hypopituitarism The other options only explain some symptoms and not account for all symptoms on their own Endocrinology A patient who has hyperparathyroidism and a prolactinoma, is at increased risk of which of the following tumours? A B C D E Neurofibroma Lung Adenocarcinoma Colorectal cancer Pancreatic endocrine tumour Carcinoid This patient has features of Multiple endocrine neoplasia (MEN 1), parathyroid hyperplasia and a pituitary adenoma i.e prolactinoma and therefore is at increased risk of pancreatic endocrine tumours https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology A 25 year old female presents with diarrhoea for approximately one month She describes this as watery with no evidence of blood or mucous She does not complain of abdominal pain, vomiting or any other symptoms She has not had anything unusual to eat and no one else is suffering from these symptoms On examination she has decreased skin turgor, has a heart rate of 100 and looks dehydrated Her bloods reveal hypokalaemia What is the most likely diagnosis? A B C D E Zollinger Ellison syndrome Phaeochromocytoma Ulcerative Colitis Gastroenteritis VIPoma The most likely diagnosis is VIPoma VIPomas are neuroendocrine tumours which secrete vasoactive intestinal polypeptide and the majority arise in the pancreas VIP is a stimulator of cAMP and in the gut this leads to massive secretion of water and electrolytes (can be up to litres per day) especially potassium and thus leads to profuse watery diarrhoea, hypokalaemia and dehydration Acidosis can also occur due to loss of bicarbonate as well as potassium 60 to 80% are malignant and metastasis Gastroenteritis is unlikely here as it is not indicated in the history and there is no vomiting or abdominal pain Zollinger Ellison can lead to watery diarrhoea however you expect features of peptic ulcer disease UC is unlikely as it tends to lead to bloody diarrhoea Endocrinology A 50 year old male presents with weight gain mainly around the face and trunk He has also noticed his arms and legs feeling weak especially when trying to get up from a seat He has noticed he is easily bruising and there is evidence of striae He is found to be hypertensive and hypokalaemic Which investigation should be performed initially? A B C D E Urinary catecholamines High dose dexamethasone CT Head and abdomen ACTH measurement Low dose dexamethasone suppression test This patient is likely to have Cushings syndrome and thus urinary cortisol and low dose dexamethasone should be performed in the first instance to confirm this is the case High dose dexamethasone and ACTH measurement provide further information about the likely underlying cause as in whether is is ACTH dependent or independent If it is thought to be ACTH independent then an adrenal gland CT scan https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi is useful If not an MRI of the pituitary should be performed to assess if there is an adenoma and thus Cushings disease Endocrinology Which of the following is not a feature of Metabolic Syndrome? A B C D E Elevated fasting glucose Elevated triglycerides Elevated HDL Central obesity Hypertension Metabolic syndrome is the whereby there is a clustering of cardiovascular risk factors and is related to insulin resistance It leads to all of the above except increased HDL level as actually there is a reduction in this Endocrinology Which drug, in addition to his metformin and gliclazide, should be given to a patient with type Diabetes Mellitus with a high urinary albumin excretion? A B C D E Ramipril Aspirin Bisoprolol Insulin Losartan ACE Inhibitors have been shown to reduce the progression of microalbuminuria to diabetic nephropathy and thus should be utilised Losartan is an angiotensin receptor II blocker and should only be utilised if an ACE Inhibitors is not tolerated Obviously good control of diabetes is also important Endocrinology For a glucose tolerance test how much glucose is used? https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi A B C D E 75 g 100 g 125g 50 g 25g 75g of glucose is dissolved in 250mls of water for a glucose tolerance test Endocrinology Which of the following is most likely to lead to a pericardial effusion? A B C D E Panhypopituitarism Graves Disease Type Diabetes Mellitus Hyperthyroidism Hypothyroidism A pericardial effusion is most likely to be seen in hypothyroidism Endocrinology A patient with type diabetes mellitus has been trying to control their cholesterol with an improved diet, however his repeat bloods reveal an LDL of 5.0 mmol/L How you manage this? A B C D E Ezetimibe Lifestyle advice Another month trial of diet control A Fibrate Simvastatin Cholesterol in a patient with diabetes should be less than 4.5 and thus a statin should be utilised As well as lowering cholesterol it has additional pleiotropic benefits and reduced cardiovascular morbidity and mortality Fibrates are more useful in hypertriglyceridaemia Ezetimibe can be used in addition if statins are not reducing cholesterol and main be used as a monotherapy if a statin is not tolerated E https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology An 18 year old presents with amenorrhoea for the last months She is asymptomatic otherwise She exercises excessively and appears underweight with a BMI of 14 What is the most likely diagnosis? A B C D E Anorexia nervosa Primary ovarian failure Coeliac disease Type Diabetes Mellitus Hypothyroidism Given the BMI of this patient, excessive exercise and the only symptom being amenorrhoea, the most likely diagnosis is anorexia nervosa Primary ovarian failure would lead to the patient failing to have her first period In hypothyroidism, Coeliac disease and type diabetes mellitus you would expect there to be other symptoms evident Endocrinology A 54 year old gentleman who is a smoker presents with a dry cough and weight loss He is also constipated with some abdominal pain has urinary frequency and is feeling fatigued and depressed He is found to have a calcium of 3.0 mmol/l What is the most likely diagnosis? A B C D E Thyrotoxicosis Sarcoidosis Hyperparathyroidism PTH like peptide secretion secondary to malignancy Addisons This patient has hypercalcaemia Although all of the options can result in hypercalcaemia, the history is suspicious of a lung cancer and thus the hypercalcaemia is most likely secondary to PTH like peptide secretion and thus hypercalcaemia Endocrinology When investigating Hyperthyroidism, which investigation should be performed to confirm the underlying diagnosis of Graves disease? https://www.facebook.com/groups/199519093570328/ MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology A 64 year old gentleman with type diabetes mellitus is found to have pre-proliferative retinopathy on his annual screening He is obese and his blood pressure is 155/90 mmHg He has evidence of proteinuria on urinalysis A recent HBA1c is 8.0% Which of the following would be most useful for reducing the progression of both the retinopathy and proteinuria? Weight reduction Intense Glycaemic control Tight blood pressure control Improved diet Smoking cessation All of the options are obviously important however to prevent the progression of both retinopathy and renal disease, blood pressure control is the most important Good glycaemic control is very important in the primary prevention of all complications of diabetes UKPDS showed that tight glycaemic control can lead to a 17% reduction in risk of progression of retinopathy and a 29% reduction in need for laser However a rapid and intense improvement in glycaemic control can actually worsen retinopathy especially in preproliferative and proliferative retinopathy Tight blood pressure control has been shown to reduce progression of retinopathy and development and progression of microalbuminuria ACE inhibitors have been shown to be very effective in reducing the progression of microalbuminuria to proteinuria and renal failure They have not yet been shown to reduce progression of retinopathy ACE inhibitors may therefore be the preferred anti hypertensive initially Endocrinology A 65 year old gentleman is on metformin and gliclazide however continues to have a HbA1c of 8.7% He is not keen to commence insulin He has previously had an episode of left ventricular failure His BMI is 21 Which of the following should be considered next? Monitor Pioglitazone Insulin https://www.facebook.com/groups/199519093570328/ 103 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Sitagliptin Exenatide In a patient with poor diabetic control despite being on maximum doses of metformin and gliclazide the next option is normally insulin or consideration of a thiazolidinedione, DPPIV inhibitor or exenatide if the patient is not appropriate for insulin therapy In this gentlemans case he is not keen for insulin and has had a previous episode of LVF and weight gain is not a concern thus sitagliptin would be the most appropriate due to the risk of pioglitazone precipitating heart failure Sitagliptin Endocrinology A 56 year old gentleman who has chronic depression and alcohol dependency syndrome visits his GP for a check up On examination he has truncal obesity, a buffalo hump and abdominal striae There also appears to be facial fullness He is hypertensive A 24 hour urinary cortisol is slight elevated and an overnight dexamethasone suppression test reveals a morning cortisol which is slightly elevated and a midnight cortisol was 70ng/L Which of the following is the most likely diagnosis? A B C D Obesity Cushing's Syndrome Ectopic ACTH Cushing's Disease https://www.facebook.com/groups/199519093570328/ 104 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi E Pseudo Cushing Syndrome Pseudo cushing syndrome and cushing syndrome can be difficult to differentiate Pseudo cushing syndrome is seen in chronic alcoholism, chronic severe anxiety and/or depression, obesity, HIV and poorly controlled diabetes It presents in the same fashion as Cushing's syndrome Some differentiating features between pseudo cushing syndrome and cushing syndrome include a midnight serum cortisol of > 75 ng/L is indicative of true cushing's syndrome and a morning cortisol post dexamethasone suppression is not suppressed to less than 50ng/L but are only slightly elevated Salivary cortisol is much higher in Cushing's syndrome as is urinary cortisol levels E Endocrinology A 33 year old woman presents with amenorrhoea and has noticed reduced axillary and pubic hair She has also noticed a change in her vision On examination she has a bitemporal hemianopia Her prolactin levels are over 2000mg/L What is the most likely diagnosis? A B C D E Macroprolactinoma Diabetes PCOS Microprolactinoma Acromegaly High prolactin levels lead to amenorrhoea and loss of sexual characteristics Macroprolactinoma is most likely as there is a mass effect as evidenced by the bitemporal hemianopia and also the level of prolactin Endocrinology In a pituitary adenoma which hormone is likely to be present in elevated amounts? A ACTH B GH C Prolactin https://www.facebook.com/groups/199519093570328/ 105 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi D TSH E FSH The prolactin level is most likely to be increased as prolactinomas are the most common pituitary adenoma and also in other adenomas there may be increased levels due to the lack of dopaminergic inhibition of its secretion due to its disruption by the tumour Endocrinology What is the mechanism of action of meglitinides? A B C D E PPARgamma agonist Stimulates insulin release from beta cells by closure of K ATP channel Stimulates insulin release form a cell by closure of K ATP channel Weight loss Reduced peripheral insulin resistance Meglitinides lead to closure of the beta cell K ATP channel stimulating insulin release This is similar to sulfonylureas Glitazones act as PPARgamma agonist and reduced peripheral insulin resistance can also be observed in sulfonylurea and metformin https://www.facebook.com/groups/199519093570328/ 106 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology A 73 year old female suffers a pathological fracture She has been complaining of constipation, anorexia, thirst and urinary frequency SHe is found to be hypercalcaemic, hypophosphataemic and a raised PTH What is the most likely diagnosis? https://www.facebook.com/groups/199519093570328/ 107 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi A B C D E Primary Hyperparathyroidism Osteomalacia Myeloma Pagets disease Bony metastases The most likely diagnosis is hyperparathyroidism There is excessive secretion of parathyroid hormone leading to hypercalcaemia and hypophoshataemia This thus results in the signs and symptoms described The diagnosis is unlikely to be Pagets or as there is normal phosphate and calcium Both Metastases and myeloma are associated with a normal or increased phosphate level Osteomalacia leads to hypocalcaemia Endocrinology A 73 year old female who is otherwise fit and well and is on no other medications, presents with bone pain and has had a recent fracture She is found to have a low calcium, low phosphate and high alkaline phosphatase What is the most likely cause? A B C D E Vitamin D deficiency due to lack of sunlight Renal disease Paget's disease Vitamin D deficiency secondary to malabsorption Myeloma The clinical features and blood results are inkeeping with osteomalacia This patient is otherwise fit and well showing no evidence of malabsorption, renal disease, liver disease or drug induced as a cause and therefore lack of sunlight is the most likely cause of the vitamin D deficiency Endocrinology A patient who is ICU is found to have a slightly low TSH, low T3 and normal T4 She has no history of thyroid disease What is the most likely cause? A Hyperparathyroidism https://www.facebook.com/groups/199519093570328/ 108 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi B C D E Euthyroid sick syndrome Hypothyroidism Pituitary Hypothyroidism Subclinical hyperthyroidism The clinical findings and the fact this patient is in ICU makes the most likely diagnosis euthyroid sick syndrome This can occur in patients who are unwell without thyroid disease The other cause for these findings is a pituitary cause of hypothyroidism however this is less likely in this case and normally T4 would also be low Endocrinology A patient suffering from hypothyroidism has her dose increased and has her bloods checked one week later Her TSH and free T4 is elevated What should you with the dose of medication? A B C D E Decrease dose Increase dose No change in dose and repeat bloods in months No change in dose and repeat bloods in one week No change in dose and repeat bloods in another weeks When altering the dose of thyroxine then one month is required before levels stabilise and thus any dose change must be done after this period of time The patient should be clinically euthyroid, they may have slightly raised free T4 levels although TSH level should be low or normal E Endocrinology A 48 year old female is suffering from oligomenorrhoea She is also complaining of tiredness, dizziness, weight gain, cold intolerance, constipation, hair and nail changes and is found to have low potassium and glucose on bloods Her FSH, LH and oestrogen levels are low What is the most likely cause of her amenorrhoea? https://www.facebook.com/groups/199519093570328/ 109 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi A B C D E Polycystic ovarian syndrome Addisons Primary ovarian failure Hypothyroidism Panhypopituitarism This patient presents with features of panhypopituitarism as there is symptoms of growth hormone, gonadotrophin, adrenal and thyroid hormone deficiencies The low FSH, LH and oestrogen is indicative of a hypothalamic cause of amenorrhoea Endocrinology A 28 year old female presents with irregular periods She is overweight and has problems with excessive hair and acne You notice she appears to have broad shoulders and a deep voice An ultrasound reveals nests of cells throughout the ovarian stroma Bloods reveal elevated testosterone levels What is the most likely diagnosis? A B C D E Ovarian hyperthecosis Polycystic ovarian syndrome Androgen producing tumour Congenital adrenal hyperplasia Cushings syndrome This patient presents with features of PCOS However there is evidence of more severe virilism and high testosterone levels making ovarian hyperthecosis more likely The ultrasound in hyperthecosis reveals nests of luteinized theca cells scattered throughout the ovarian stroma where as in polycystic ovarian syndrome this is confined to cystic follicle area https://www.facebook.com/groups/199519093570328/ 110 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Sonographically normal ovary with SH Transvaginal sonography in a 43-year-old patient shows a normal-appearing right ovary (calipers) The ovarian volume was 11.5 cm3 (upper limits of normal for age) https://www.facebook.com/groups/199519093570328/ 111 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Coexistent SH and PCO Transvaginal sonography in a 37-year-old patient shows an enlarged left ovary (arrows) with multiple small peripheral follicles and prominent central stroma The right ovary had a similar sonographic appearance The sonographic features are typical of PCO https://www.facebook.com/groups/199519093570328/ 112 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Solid mass due to the nodular form of SH Transvaginal sonography in a 60-year-old patient shows a small solid mass (calipers) within the right ovary, corresponding to nodular SH Endocrinology A 37 year old male presents due to loss of libido and erectile dysfunction He has also noticed a small lump in his testes On further questioning he has been suffering from headaches and tiredness over the last few months Bloods reveal a low testosterone level and GnRH levels are also low There is a mild elevation of prolactin There is evidence of an elevated IGF1 levels Which of the following is the most likely diagnosis? A B C D E Testicular Cancer - Teratoma Testicular Cancer - Seminoma Hypothyroidism Vascular Disease Pituitary Adenoma The finding of elevated IGF1 suggests acromegaly which is caused by a pituitary adenoma secreting excessive amounts of growth hormone When the pituitary adenoma is large this can https://www.facebook.com/groups/199519093570328/ 113 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi lead to hypopituitarism The patient has a low libido and erectile dysfunction due to hypogonadotrophic hypogonadism as both GnRH and testosterone levels are low The patient should be investigated due to the finding of a lump in his testes however testicular cancer would not lead to hypogonadotrophic hypogonadism Raised IGF1 levels have been associated with risk of testicular cancer however there is conflicting evidence about it's role with some suggesting it is inversely associated or not associated at all Endocrinology A 60 year old male presents with headaches On examination he appears to have very large hands and a prominent jaw He is hypertensive and appears to be sweating profusely Which of the following is useful in the first instance for the diagnosis? A B C D E IGF1 levels followed by growth hormone levels before and after glucose tolerance test Cortisol levels Glucose levels Growth hormone levels Short synacthen The clinical features of change in appearance with large jaw and hands is indicative of the diagnosis of acromegaly Other features include macroglossia, headaches, visual field defects, excessive sweating, carpal tunnel syndrome and hypertension and impaired glucose tolerance Galactorrhoea can also occur In growth hormone there will be an elevated IGF1 and the diagnosis is confirmed when growth hormone is not suppressed with glucose tolerance test Panhypopituitarism can occur due to compression and the other hormones should be measured An MRI may locate the pituitary adenoma which results in acromegaly There is an excessive risk of colorectal cancer in acromegaly and therefore colonoscopy should be offered Transphenoidal surgery is the treatment of choice Somatostatin analogues such as octreotide, can be used for medical management and have overtaken dopamine agonists such as bromocriptine and cabergoline Pegvisomant is a human growth hormone analogue and is a highly selective antagonist It is utilised in those who have inadequate response to surgery or other medical treatments Endocrinology https://www.facebook.com/groups/199519093570328/ 114 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi A 42 year old female presents with malaise, night sweats and weight loss She has also noticed tender bruise like lesions on her shins A CXR reveals bilateral hilar lymphadenopathy She has also noticed polydipsia, polyuria and constipation over the last few weeks and bloods reveal hypercalcaemia Given the most likely diagnosis, what is the cause of her hypercalcaemia? A B C D E Secretion of PTH like peptide Hyperparathyroidism Bony metastases Reduced Urinary calcium excretion Increased hydroxylation of Vitamin D This history is highly indicative of sarcoidosis In sarcoidosis there is formation of granulomas Within these granulomas the macrophages lead to increased alpha hydroxylation of vitamin D and thus hypercalcaemia Endocrinology A 27 year old gentleman presents with recurrent episodes of sweating, palpitations, dizziness and weakness He has noticed them occurring particularly in the early morning During one of these episodes his BM is found to be 2.9 Which of the following investigation will be most useful in confirming the diagnosis? A B C D E Glucose tolerance test Random glucose, insulin, proinsulin and c peptide levels Fasting (48 hours or 72 hours) glucose, insulin, proinsulin and c peptide levels Fasting glucose C peptide level The most likely diagnosis to consider is an Insulinoma They are the most comon neuroendocrine tumour and the majority are found in pancreatic islet cells 90% are benign whilst 10% are malignant They are a feature of MEN type Diagnosis is made via a fasting glucose, C peptide, insulin and proinsulin levels Traditionally a 72 hour fast was utilised however many have shortened this to 48 hours Sulfonylureas should also be screened for In self administered insulin, c peptide levels would be low and therefore measuring c peptide alone is only useful in excluding this as it will be normal or elevated in insulinoma or sulphonylurea abuse Glucose tolerance test are utilised in the diagnosis of diabetes mellitus Insulin stress tests are not indicated https://www.facebook.com/groups/199519093570328/ 115 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology Which of the following is not useful in the management of thyroid eye disease? A B C D E Radiotherapy Radioiodine therapy Steroids Orbital Decompression Ciclosporin All of the options can be utilised in the management of thyroid eye disease however radioiodine therapy can lead to a worsening of thyroid eye disease and should therefore be avoided in patients with severe thyroid eye disease Endocrinology A 32 year old female presents with a lump in her neck which is deemed to be of thyroid origin It is giving her some problems with swallowing Her thyroid function tests are normal and an ultrasound is arranged A radionuclide uptake scan is organised and shows a cold nodule and her FNA is suspicious of follicular carcinoma How would you manage this patient? A B C D E Total thyroidectomy, radioiodine therapy and oral replacement Total Thyroidectomy Watch and Wait Radioiodine therapy and oral replacement Thyroxine The management of follicular carcinoma is thyroidectomy, followed by radioiodine therapy which also treats metastases followed by oral thyroxine replacement Endocrinology https://www.facebook.com/groups/199519093570328/ 116 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi A 30 year old female who has been recently unwell with a flu like illness presents with a painful and tender swelling in her neck She is feeling anxious, intolerant to heat and suffering from palpitations Her TSH is reduced and T4 is elevated What is the most likely diagnosis? A B C D E De Quervains thyroiditis Multinodular goitre Pharyngitis Thyroid malignancy Hashimoto thyroiditis This patient is presenting features of hyperthyroidism The clue to the underlying cause if the viral illness and tender goitre which typifies De Quervains thyroiditis Viruses such as coxsackie, EBV, mumps and adenovirus have been implicated This is the thyrotoxic phase which lasted about to weeks which is then followed by a euthyroid period for to weeks then a hypothyroid phase which can be a few weeks to months and can be permanent in about 10 percent In the rest full recovery occurs https://www.facebook.com/groups/199519093570328/ 117 ... edition of MRCP Part Endocrinology best of five that I have had the honor of working on MRCP Part Endocrinology best of five is a part of a huge work include all sections of internal medicine Endocrinology, .. .MRCP Part Endocrinology Best of five By Dr Hakim Assalahi MRCP Part Endocrinology Best of five EDITED BY Dr Hakim Assalahi 1st Edition 2 014 https://www.facebook.com/groups /19 9 519 093570328/ MRCP. .. https://www.facebook.com/groups /19 9 519 093570328/ 28 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi Endocrinology https://www.facebook.com/groups /19 9 519 093570328/ 29 MRCP Part Endocrinology Best of five By Dr Hakim Assalahi