Explanation:

The raised prolactin would most likely reflect stalk compression in this patient. Otherwise, the normal cortisol would be unhelpful as is the normal thyroid-stimulating hormone (TSH). The elevated luteinising hormone (LH) is a reflection of this patient being menopausal. Growth hormone (GH) concentrations are frequently undetectable as they are released episodically usually during the night.

Explanation:

Papillary cancer is the most common type of thyroid cancer, accounting for 60 to 70% of all thyroid cancers. About 2 to 3 times as many women as men have papillary cancer. Papillary cancer is more common in young people but grows and spreads more quickly in older people. People who have received radiation treatment to the neck, usually for a noncancerous condition in infancy or childhood or for some other cancer in adulthood, are at greater risk of developing papillary cancer.

Explanation:

Even mild chronic excess thyroid hormone replacement over many years can cause bone mineral resorption, increase serum calcium levels, and lead to osteoporosis. The elevated calcium decreases parathyroid hormone. Goiter is an indicator not a cause for hormone replacement. Osteoarthritis is related to thyroid hormone replacement.

Explanation:

Explanation:

Insulin works by directly pushing glucose from the bloodstream into the cells. Metformin works by inhibiting hepatic gluconeogenesis. Glyburide is an oral sulfonyl urea hypoglycemic drug that increases pancreatic insulin secretion. Acarbose inhibits enzymes needed to digest carbohydrates. Because the carbohydrates are not broken down into glucose molecules, less glucose is absorbed into the bloodstream. Metformin is contraindicated in people with any condition that could increase the risk of lactic acidosis, including liver and kidney disorders (creatinine levels over 150µmol/I).

Explanation:

In primary hyperaldosteronism (Conn´s disease), overproduction of aldosterone leads to fluid retention and increased blood pressure, weakness, and, rarely, periods of paralysis.
Hyperaldosteronism can be caused by a tumor in the adrenal gland or may be a response to some diseases. High aldosterone levels can cause high blood pressure and low; potassium levels; low potassium levels may cause weakness, tingling, muscle spasms, and periods of temporary paralysis. Doctors measure the levels of sodium, potassium, and aldosterone in the blood. Sometimes, a tumor is removed, or people take drugs that block the action of aldosterone.
Doctors who suspects hyperaldosteronism first tests the levels of sodium and potassium in the blood. Doctors may also measure aldosterone levels. If they are high, spironolactone or eplerenone, drugs that block the action of aldosterone, may be given to see if the levels of sodium and potassium return to normal. In Conn´s syndrome, the levels of renin are also very low. When too much aldosterone is being produced, doctors examine the adrenal glands for a noncancerous tumor (adenoma). Computed tomography (CT) or magnetic resonance imaging (MRI) can be helpful, but sometimes blood samples from each of the adrenals must be tested to determine the source of the hormone.

Explanation:

Kallman´s syndrome may arise due to abnormalities of the KAL-1 or KAL- gene (encoding anosmin-l and FGF-l). Whilst the majority of cases are sporadic, perhaps up to 50% of cases are due to genetic inheritance. Kallman´s presents with hypothalamic gonadotrophin releasing hormone deficiency and deficient olfactory sense – hyposmia or anosmia. It can occasionally be associated with optic problems, such as colour blindness or optic atrophy. FISH, using a specific chromosomal probe, is currently the best means of a genetic diagnosis of this condition.

Explanation:

Diabetes Mellitus is diagnosed on the basis of symptoms plus a random glucose above 11.1mmol/1 or fasting plasma glucose above 7mmol/l or the two hour oral glucose tolerance test. Impaired glucose tolerance would be indicated by a post OGTT plasma glucose between 7.7 and 11.1 or a fasting plasma glucose between 6.1 and 7.

Explanation:

Hypothyroidism is not an uncommon of hyperprolactinemia, and should be part of the work up of all patients with an elevated prolactin. The clinical scenario here would be consistent with a diagnosis of hypothyroidism, Macroprolactin may masquerade as hyperprolactinemia and most laboratories now carry out this assay if requested in patients with hyperprolactinemia. Cabergoline or Bromocriptine should only be commenced if a macroprolactinoma is confirmed. A bulky pituitary gland on CT scan is not a significant finding and an MRI of the pituitary is required to delineate the anatomy of the pituitary gland. Bitemporal hemianopia would be a feature of a macro prolactinoma impinging on the optic chiasm.

Explanation:

In primary hyperaldosteronism (Conn´s disease), overproduction of aldosterone leads to fluid retention and increased blood pressure, weakness, and rarely, periods of paralysis. Hyperaldosteronism can be caused by a tumor (usually a non-cancerous adenoma) in the adrenal gland or may be a response to some diseases. High aldosterone levels can cause high blood pressure and low potassium levels; low potassium levels may cause weakness, tingling, muscle spasms, and periods of temporary paralysis. Doctors measure the levels of sodium, potassium, and aldosterone in the blood. Sometimes, a tumor is removed, or people take drugs that block the action of aldosterone.

Explanation:

In Cushing´s syndrome, the level of corticosteroids is excessive; usually from overproduction by the adrenal glands. Corticosteroids alter the amount and distribution of body fat. Excessive fat develops throughout the torso and may be particularly noticeable at the top of the back. A person with Cushing´s syndrome usually has a large, round face (moon face). The arms and legs are usually slender in proportion to the thickened trunk. Muscles lose their bulk, leading td weakness.
High corticosteroid levels over time raise the blood pressure, weaken bones (osteoporosis), and diminish resistance to infections. The risk of developing kidney stones and diabetes is increased and mental disturbances, including depression and hallucinations, may occur. Women usually have an irregular menstrual cycle. Children with Cushing´s syndrome grow slowly and remain short. In some people, the adrenal glands also produce large amounts of androgens (testosterone and similar hormones), leading to increased facial and body hair in women and balding. When doctors suspect Cushing´s syndrome, they measure the level of cortisol, the main corticosteroid hormone, in the blood. Normally, cortisol levels are high in the morning and lower late in the day. In people who have Cushing´s syndrome, cortisol levels are very high throughout the day.

Explanation:

Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facies, hoarse slow speech, and dry skin, and by low levels of thyroid hormones. Serum TSH is the most sensitive test. In primary hypothyroidism, there is no feedback inhibition of the intact pituitary, and serum TSH is always elevated, whereas serum free T4 is low. In secondary hypothyroidism, free T4 and serum TSH are low (sometimes TSH is normal but with decreased bioactivity). Management includes treatment of the underlying cause and administration of thyroxine.

Explanation:

Intracytoplasmic sperm injection, is a long, fancy way of saying “inject sperm Into the middle of the egg”. ICSI is a very effective method to get fertilization of eggs in the IVF lab after they have been retrieved from the female partner. This will usually result in normal fertilization in approximately 70-85% of eggs Injected with viable sperm.
Currently recommendations for vitro fertilization (IVF) with ICSI are for:
1. All couples with severe male factor infertility that do not want donor sperm insemination.
2. All couples with infertility with: Sperm concentrations of less than 15-20 million per milliliter or sperm motility less than 35% or very poor sperm morphology. 3. All couples having IVF who have had a previous cycle with no fertilization or a low rate of fertilization (low percentage of mature eggs that are normally fertilized).

Explanation:

Explanation:

Renal stones due to hypercalciuria are a common presentation of primary hyperparathyroidism. The other conditions are not associated with the nephrolithiasis.

Explanation:

Explanation:

This woman has Riedel thyroiditis, an uncommon form of chronic (possibly autoimmune) thyroiditis that is characterized by dense fibrosis that destroys the thyroid gland and also extends into the adjacent muscle and connective tissue of the neck. The condition is clinically important because it may mimic malignancy. Masses of hyperplastic follicles are a feature of multinodular goiter. Multinucleated giant cells are a feature of de Quervain thyroiditis. Lymphocytic infiltration is a part of many thyroid diseases, but is seen in isolation in subacute lymphocytic thyroiditis. Sheets of lymphocytes with gland destruction are seen in Hashimoto thyroiditis.

Explanation:

Multiple endocine neoplasia syndromes are inherited as autosomal dominant disorders. MEN II is separated in to types IIA and IIB (or III).You should recognize this as a probable case of MEN III (formerly MEN IIB). Features of this condition include medullary carcinoma of the thyroid, pheochromocytoma, oral and intestinal ganglioneuromatosis (including mucosal neuromas) and marfanoid habitus without hyperparathyroidism. Also remember, that Type IIA is associated with primary hyperparathyroidism, medullary carcinoma of the thyroid, and pheochromocytoma. Gastrinomas and insulinomas are found in MEN I. Parathyroid adenomas are found in MENI and II. Pituitary adenomas are found in MEN I.

Explanation:

Explanation:

Turner´s syndrome (only one X sex chromosome 45XO) is associated with ovarian failure and lack of estrogen production. Thus, FSH and LH are not inhibited and, consequently, the levels are both elevated.

Explanation:

Adenocarcinoma of the lung is not specifically associated with diminished testosterone effects. Hemochromatosis, chronic hemodialysis, sickle cell anemia, and cirrhosis of the liver can all be associated with undervirilization in men.

Explanation:

Estrogen receptors are distributed widely in body tissues, including the brain. Limited evidence suggests that estrogen and progesterone modulate central nervous system neuronal activity and that estrogen deficiency contributes to the neurodegenerative changes of aging. Some studies suggest that estrogen replacement therapy may protect against Alzheimer´s disease in women and may improve cognitive performance of women with this illness. There is still not enough evidence to recommended estrogen-replacement therapy for this reason alone. Estrogen is the agent of choice for preventing postmenopausal bone loss and also for risk reduction for hip fracture up to 50%. Estrogen replacement therapy is useful in vaginal atrophy with associated dysuria, pruritis, incontinence, and dyspareunia. Estrogen indisputably is effective in controlling vasomotor complaints, such as hot flashes and night sweats. These symptoms are experienced by 75-85% of climacteric women and may persist for months to years. Estrogen replacement provides a cardioprotective effect, which may be a result of reduced LDL cholesterol, increased HDL cholesterol, reduced plasma fibrinogen levels, or increased fibrinolytic potential. Epidemiologic studies have estimated that estrogen reduces the risk of ischemic heart disease by as much as 50%.

Explanation:

A decrease in T3 levels is accompanied by an increase in serum rT3 used by a decrease in plasma clearance of rT3 due to inhibition of its 5´-monodeiodination. The low T3, normal T4 variant, is the most frequently encountered variant of the sick euthyroid syndrome. The decrease in serum T3 correlates roughly with the severity of the underlying systemic illness. The decreased production of T3 results from impairment of extrathyroidal conversion of T4 to T3. Normal serum T4 and TSH levels distinguish this syndrome from hypothyroidism.

Explanation:

Pseudohypoparathyroidism is manifested by elevated plasma parathyroid hormone levels, hypocalcemia, hyperphosphatemia, and peripheral resistance to parathyroid hormone action. Panhypopituitarism would be associated with low plasma parathyroid levels and no peripheral resistance. Acute tubular necrosis does not cause this constellation of findings. Primary and secondary hypoparathyroidism are associated with low plasma levels of PTH and no peripheral resistance to PTH.

Explanation:

The clue to the answer in this question is that this patient has a family history of diabetes. Long term corticosteroid therapy in a patient with a family history of diabetes may increase the chance of a patient developing that disease. Patients without any risk factors may experience increased levels of glucose in the blood. Symptoms such as polyuria and weight loss may be masked by the disease for which the patient is taking steroids. Measurement of 1, 25-dihydroxy vitamin D the active vitamin D metabolite, would not be recommended. Corticosteroids can alter calcium balance mainly to due vitamin D deficiency secondary to impaired intestinal absorption of calcium, but 25-hydroxy vitamin D is a better marker for assessing nutrition. PTH, an 84 amino acid polypeptide, can be cleaved into an active N-terminal fragment and an inactive C-terminal fragment. Measurement of C-terminal PTH is not recommended. Although PTH is a regulator of calcium homeostasis, these fragment molecule measurements have not been found to correlate well with true PTH activity on bone. Although PTH is a calcium regulator in the body, it is not considered a major contributor to corticosteroid induced bone loss, so measurement of intact parathyroid hormone is not the best choice. It is only significant if a person has underlying malabsorption such as that occurring with inflammatory bowel disease. Serum protein electrophoresis is used mainly for the diagnosis of multiple myeloma in patients with pathologic fractures or a high clinical suspicion of myeloma.

Explanation:

This number is worth remembering. While there is some variation from individual to individual, glucosuria usually occurs when the blood level is more than 180- 200 mg/dL. The underlying physiology is that glucose is freely filtered at the glomerulus but then reabsorbed as it passes along the proximal tubule. If the filtered glucose load is too great, then it cannot be completely resorbed. In patients with longstanding type 1 diabetes mellitus, the renal threshold may be highly variable secondary to renal disease.

Explanation:

A tough question. The specific features that would support a diagnosis of Graves would include exophthalmos, thyroid bruit and pretibial myxoedema. The latter is pathognomonic, as exophthalmos may be a feature (rarely) of hashitoxicosis.

Explanation:

This woman has features of spontaneous hypoglycaemia which is relieved by eating and precipitated by fast and exercise. The most relevant investigation to prove or disprove this would be a 72 hr fast which a virtual 99% sensitivity. If proven then further investigation for insulinoma or factitious hypoglycaemia is warranted.

Explanation:

This patient presents with deteriorating tiredness and weight gain after having had pituitary surgery for a non-functioning pituitary tumor. He has associated anterior hypopituitarism but is receiving appropriate and stable replacement therapy. However, these symptoms are typical of an untreated adult growth hormone deficiency and reductions in quality of life, reduced energy and detrimental changes in body composition are well recognised. Recent evidence would suggest that GH replacement therapy in addition to his current replacement therapy does improve symptoms and quality of life and is endorsed by NICE guidance. The renin-aldosterone system is independent of the hypothalamo- pituitary axis and therefore aldosterone is not necessary. The patient does not have any symptoms of thirst or polyuria and therefore vasopressin deficiency is also an unlikely cause of his problems. Whilst depression or somatisation are possibilities it is important to recognise that the symptoms of tiredness and the weight gain is more in keeping with GH deficiency and no other features of either of the former diagnoses are suggested.

Explanation:

This patient has a coincidentally noted pituitary tumor, has no endocrine symptoms and appears to have normal endocrine function although we are not provided with information pertaining to cortisol secretory function nor GH. With this caveat in mind, the most appropriate strategy would be observation and repeat scanning.

Explanation:

Cases of Cushing´s Syndrome have presented with necrosis of the femora head due to osteoporosis. Diabetes insipidus would be very unusual, whereas diabetes mellitus may occur in 30%. Lichen planus is treated with corticosteroids, as is polymyositis. Mononeuritis multiplex is not feature.

Explanation:

Drugs causing hirsutism/hypertrichosis include minoxidil (not moxonidine -a centrally acting antihypertensive), phenytoin (not valproate) and cyclosporin.
Polycystic ovaries and congenital adrenal hyperplasia are associated with increased androgens and hirsutism. Hypoadrenalism may be associated with loss of hair especially Pubic hair. Treatment of hirsutism is with anti-androgens (cyproterone, spironolactone), reduction of free androgens (oestrogen therapy, OCP, weight loss), and cosmetic treatment for removal of hair.

Explanation:

Of the drugs listed only rosiglitazone would boost insulin sensitivity. Other thiazolidinediones such as pioglitazone would also do this, as well as the more widely prescribed metformin! Gliclazide, glimepiride and repaglinide are insulin secretagogues -they boost insulin secretion. Acarbose has a modest effect on the absorption of sugars from the gut, but its main effect is to cause flatulence. Type 2 diabetes is due to two defects-insulin resistance and insulin deficiency. In 95% of patients it is insulin resistance that is the main cause of the diabetes. These patients are typically obese with features of the metabolic syndrome. The bulk of the insulin resistance appears to be in skeletal muscle. The state of insulin resistance is associated with abnormal glucose metabolism (obviously) and excessive free fatty acids in the blood. Drugs and lifestyle modifications that increase insulin sensitivity (and thereby reduce insulin resistance) help to reverse these abnormalities).

Explanation:

GH is rarely associated with BIH; the mechanism probably is related to fluid retention. The commonest side effect of GH therapy is fluid retention, though other side effects include gynaecomastia, hypertension and atrial fibrillation. Benign prostatic hyperplasia (BPH) has not been reported.

Explanation:

Explanation:

Inferior petrosal sinus sampling with an elevated central adrenocorticotropic hormone (ACTH) concentration compared with the peripheral value is the most valuable test in the differential diagnosis of either cushing´s disease or ectopic Cushing´s syndrome. The other tests are far less useful in comparison.

Explanation:

Superior extension of the tumour can lead to compression of firstly the optic apparatus and later the hypothalamus.
Lateral extension of the tumour with compression or invasion of the cavernous sinus can compromise third fourth or sixth cranial nerve function, manifest as diplopia in 5 to 15 % of pituitary tumour patients.
The optic chiasm lies 5-10mm above the diaphragm sellae and anterior to the stalk.
Adenomas larger than 1.5cm frequently have suprasellar extension and a magnetic resonance imaging (MRI) scan will show compression and upward displacement of the optic chiasm.

Explanation:

Cushing´s syndrome is one of the secondary causes of hypertension. Therefore the blood pressure would be high. Along with Cushing´s, the other causes include Hyperaldosteronism, Aortic coarctation, Pheochromocytoma and Stenosis of renal artery. Remember the mnemonic C.H.A.P.S. for these 5 causes of secondary hypertension.

Explanation:

A low caloric intake not only interferes with the nutritional needs of a young and growing organism, but also interferes with the homeostatic mechanisms necessary to maintain functioning. Undernutrition and weight loss associated with anorexia nervosa either reverse pubertal changes and prevent menarche from occurring (primary amenorrhea) or regress the hyperthalamo-pituitary-gonadal axis to prepubertal regulation, resulting in low LH, low FSH and minimal estrogen and progesterone plasma levels (secondary amenorhhea).

Explanation:

During chronic total parenteral nutrition, deficiencies in trace elements may manifest. Deficiency in zinc can produce a rash; poor wound healing, alopecia, and taste and smell disturbances. Copper deficiency may manifest as an iron-unresponsive anemia or pancytopenia. Chromium deficiency may produce glucose intolerance. Selenium deficiency may present as proximal neuromuscular weakness. Manganese deficiency may present with weight loss, altered hair pigmentation, and low serum triglycerides.

Explanation:

Thyroid stimulating hormone is secreted by the pituitary gland, and it is the most sensitive test to detect and diagnose hypothyroidism. The third generation assay for TSH is available. Hashimoto´s thyroiditis is the most common cause for hypothyroidism. The T³ resin uptake (A) measures the unoccupied plasma binding sites for T⁴ and T³ and thereby provides an indirect assessment of free hormone concentration. A low T³ RU indicates a high binding capacity and is seen in hypothyroidism, pregnancy and estrogen administration. This test is now outdated and clinicians use the TSH instead. Anti-microsomal antibodies (B) and thyroglobulin antibodies are present in autoimmune thyroid states such as Hashimoto´s thyroiditis and Grave´s disease. Serum thyroglobulin (D) is increased in patients with an enlarged thyroid or following acute trauma to the thyroid. Thyroglobulin determinations are most useful in the follow-up of patients with metastatic thyroid carcinoma following thyroidectomy. Reverse T³ (E) derives from the peripheral metabolism of T⁴ to T³. Its measurement is not generally useful clinically.

Explanation:

Diabetes mellitus is not associated with hirsutism, but neuropathy (A), nephropathy (B), retinopathy (C), and gastroparesis (D) all can occur in diabetes.

Explanation:

The condition described in the question stem is very common among diabetics, and is due to atrophy of lumbricals and interosseus muscles secondary to diabetic neuropathy. Another finding that may be seen is the presence of corns and callosities on the dorsal surface of the feet overlying the protuberant interphalangeal joints. All of these degenerative changes add to the diabetic´s foot disease, predisposing for sores that heal poorly in the poorly vascularized diabetic foot, often leading to gangrene and requiring amputation of the distal toot. Flexor digitorum longus is an extrinsic muscle of the foot that flexes the distal phalanges of the lateral four toes and assists in plantar flexion of the foot. Peroneus longus is an extrinsic muscle of the foot that plantar-flexes and everts the 4 foot. Tibialis anterior is an extrinsic muscle of the foot that dorsi flexes and inverts the foot.

Explanation:

Maturity onset of diabetes in the young must be differentiated from juvenile onset diabetes (or insulin dependent diabetes mellitus). IDDM is an autoimmune disorder in which anti islet cell antibodies and T cells reactive with islet cell antigens destroy beta cells within the islets. Mature onset of diabetes in the young, or MODY, is similar to non insulin dependent diabetes except that it occurs in children. Therefore, as with IDDM, the protein that is thought to be defective is the glucokinase cell surface protein.

Explanation:

Ectopic production of thyroid hormones caused by conditions such as an ovarian teratoma result in thyrotoxicosis. Primary hypothyroidism accounts for more than 90% of the cases of hypothyroidism. Autoimmune destructive processes, such as Hashimoto´s thyroiditis or Grave´s disease, eventually result in hypothyroidism. Drugs, such as lithium and sulfonamides, which interfere with thyroid hormone biosynthesis, also result in the condition. Secondary hypothyroidism results from deficient pituitary thyrotrophs. Conditions, such as neoplasms, surgery or Sheehan´s syndrome, which result in panhypopituitarism, cause hypothyroidism. Hypothalamic hypothyroidism, due to decreased TRH secretion, leads to decreased secretion of TSH. Conditions, such as sarcoidosis, which may infiltrate the hypothalamus, or infectious processes, may also lead to hypothyroidism.

Explanation:

Insulinomas are not associated with insulin resistance. All of the other conditions are associated with such resistance.

Explanation:

First degree heart block is not associated with hypocalcemia. The electrocardiographic finding that is associated with hypocalcemia is a prolonged QT interval. Tetany, seizures, bronchospasm, and paresthesias all are manifestations of hypocalcemia.

Explanation:

Type 1 diabetes mellitus most commonly occurs in children secondary to decreased blood insulin levels. In type 1 diabetes the lack of insulin production is caused by an autoimmune mediated destruction of insulin producing beta cells. As a result of this autoimmune process1 patients with type 1 diabetes generally have circulating islet cell antibodies, which include anti-glutamic acid decarboxylase (anti-GAD) antibodies. Furthermore this condition is linked to HLA types DR3, DR4, and DR3/4. The only FDA-approved treatment measure for type 1 diabetes mellitus is insulin. Metformin is indicated for the treatment of type 2 diabetes mellitus. Type 2 diabetes is not an autoimmune process and would therefore not be HLA-linked or be associated with the presence of islet cell antibodies. Amphetamine salts are commonly used in the treatment of ADD (attention deficit disorder) and ADHD (attention deficit hyperactivity disorder) in children. Captopril is an ACE (angiotensin-converting enzyme) inhibitor commonly used in the treatment of heart failure and hypertension.

Explanation:

Prolactin receptors are located on Leydig cells in the testes. Under normal conditions, prolactin synergizes with LH to stimulate testosterone production by Leydig cells. In males with hyperprolactinemia secondary to a pituitary tumor, elevated prolactin levels interfere with testosterone production. Excessive prolactin reduces the number of LH receptors and/or inhibits intracellular events stimulated by LH. Hyperprolactinemia may also decrease the pulsatile nature of LH secretion, also causing a decrease in testosterone production. Testosterone production is required for spermatogenesis, so elevated prolactin decreases sperm count and frequently causes infertility. An increase in FSH, LH, and LHRH would increase testosterone production rather than decrease it. LHRH is released from the hypothalamus and acts on the anterior pituitary to stimulate LH and FSH release. LH acts on the Leydig cells of the testes to increase testosterone production which acts on the Sertoli cells to facilitate spermatogenesis. An increase in testosterone would result in an increase in spermatogenesis and would not result in infertility.

Explanation:

Factitious hypoglycemia, or self-induced hypoglycemia, is a psychological disorder that results from surreptitious self injection with insulin. It is most commonly seen in healthcare professionals or in diabetic patients or their relatives. The key to diagnosing this disorder is that injectable insulin preparations do not contain any C-peptide. Hence, the injected insulin (which explains the increased plasma insulin concentration) produces hypoglycemia. The hypoglycemia then suppresses beta-cell secretion of endogenous insulin and C-peptide. Dumping syndrome can produce a non-fasting hypoglycemia. This is a reactive hypoglycemia produced by excessive secretion of insulin after rapid discharge of ingested carbohydrate into the small intestine in patients with previous gastrectomy. The excessive insulin secretion may be clue to overstimulation of parasympathetic reflexes or to increased secretion of insulinotropic gut peptides. The increase in insulin secretion would be accompanied by an increase in C-peptide secretion. Patients with growth hormone deficiency can also experience hypoglycemic episodes, especially when fasting. Growth hormone has an anti-insulin action, and when this hormone is deficient, the ability of insulin to induce hypoglycemia is increased. Growth hormone deficiency could not explain the increase in plasma insulin and decrease in plasma C peptide. Insulinoma also produces tasting hypoglycemia due to uncontrolled secretion of insulin by a beta-cell tumor. However, in this case, plasma insulin and C-peptide will both be increased, since the two polypeptides are secreted by beta cells in a one to one molar ratio. Pheochromocytoma results from a catecholamine-secreting tumor. If anything, blood glucose is increased in this disorder. The excess catecholamines stimulate glycogenolysis and also suppress insulin secretion.

Explanation:

According to the new revised criteria for the diagnosis of diabetes, venous plasma glucose (VPG) of 6.1 – 6.9 is categorised as impaired fasting glycaemia and requires further assessment with a 75 gram oral glucose tolerance test (OGT) which is still the gold standard. A two hour value of equal to or over 11.1mmol/1 is diagnostic of diabetes. Impaired glucose tolerance is a two hour VPG of 7.8 -11.1 during an OGT. Initial treatment of Type 2 diabetes is patient education, diet and lifestyle changes.

Explanation:

Individuals with IGT are at significant risk of progression to type 2 diabetes. A number of studies have looked at the absolute risk of progression from IGT to type 2 diabetes. The large and widely quoted Hoorn study which looked at 1342 Caucasian non diabetic subjects found that 33.8% progressed to type 2 diabetes over 6 years follow up. This increased to 64.5% if individuals had both IGT and IFG. A similar rate of progression for individuals with IGT was Vaccaro who studied a Caucasian group in Italy. Intensive lifestyle changes involving diet changes, regular exercise and weight loss have been shown to reduce the rate of progression to type 2 diabetes.

Explanation:

This patient presents with weight loss, and reduced quadriceps strength, bilaterally with absent knee reflexes. This is a typical presentation of diabetic amyotrophy.
Osteomalacia, hyperthyroidism and Cushing´s would be unlikely as the proximal myopathy involves quadriceps and hamstrings and knee reflexes would be preserved. Subacute combined degeneration of the cord does not present with such features.

Explanation:

Benefits of growth monitoring include early detection of conditions such as:

• Growth hormone insufficiency
• Hypothyroidism
• Syndromes: Turner, Russell-Silver, Noonan´s, skeletal dysplasias
• Growth impairment, for example, coeliac disease, inflammatory bowel disease or chronic renal failure
• Intracranial tumours
• Short normal children
• Children with short stature
• Health promotion: impaired growth may be associated with child abuse or neglect for example
• Focus of interest for parents. Public health aspects:
• Secular trend of increasing growth
• Linking growth patterns in fetal life and early infancy with adult patterns of disease
• Link between height and social circumstances.

Explanation:

The diagnosis is usually relatively easy to confirm in a symptomatic subject. A random glucose of more than 11.1mmol/L or a fasting glucose of more than 7.0mmol/L would be regarded as confirmatory. There is usually glycosuria in addition to ketonuria. Isolated ketonuria suggests fasting. Raised glycosolated haemoglobin (HbA1c) is also highly suggestive but not diagnostic. A glucose tolerance test is rarely needed.

Explanation:

Despite the advances in the management of diabetes in general and the improvements in intensive care, studies reveal that the mortality associated with diabetic ketoacidosis remains stubbornly around 2-5% since 1970s.
Specifically, mortality relates to cerebral oedema.

Explanation:

Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormone and a slowing of vital body functions. Insufficient thyroid hormone causes body functions to slow. Symptoms are subtle and develop gradually. They may be mistaken for depression, especially among older people. Facial expressions become dull, the voice is hoarse and speech is slow, eyelids droop, and the eyes and face become puffy. Many people with hypothyroidism gain weight, become constipated, and are unable to tolerate cold. Hypothyroidism is common, especially among older people, particularly women; it affects about 10% of older women. It can, however, occur at any age. Very severe hypothyroidism is called myxedema. Diagnosis is made by obtaining TSH and Free T4 levels. Treatment is with thyroid replacement with synthroid.

Explanation:

Explanation:

Explanation:

All of the answer choices are useful therapeutic modalities with exception of avoiding water. They should wash their feet to keep them clean and also passively to have a look at their feet. Diabetics should be outfitted with wide-based well-broken-in shoes. Meticulous foot care and exams are the best preventive measures.

Explanation:

This patient has inadequately treated insulin dependent diabetes. The goal serum glucose for therapy is < 120 mg/dL. Since there is no indication that the insulin type is incorrect (hypoglycemia), the patient simply requires an increased dosage of his current insulin type. Metformin is an oral antihyperglycemic agent that acts by increasing peripheral utilization of glucose. The primary purpose of medications such as this is to delay or avoid the requirement for exogenous insulin. Once a patient is on insulin, these drugs are of little benefit. Secondarily, most patients with non insulin dependent diabetes have relative “insulin resistance” and it is for this reason that glucose utilization drugs are employed as first line management. This patient´s symptoms of increased weight loss and appetite are a function of his poor glucose control, not of inadequate caloric intake. Poorly controlled insulin dependent diabetics are often thin as they waste muscle to liberate glucose in an attempt to provide glucose for the body. The defect is with the inability to utilize the glucose already present so the end result is hyperglycemia and muscle wasting. For similar reasons, there is no need to alter his caloric distribution.

Explanation:

Rebound hyperglycemia, also known as the Somogyi phenomenon, typically produces the pattern such as this. Such patients usually respond best to lowering insulin doses, rather than elevating them. Stress would not produce these symptoms, nor would apathetic hyperthyroidism or bulimia.

Explanation:

Thyroid stimulating hormone is secreted by the pituitary gland, and it is the most sensitive test to detect and diagnose hypothyroidism. The third generation assay for TSH is available. Hashimoto´s thyroiditis is the most common cause for hypothyroidism. The T3 resin uptake (A) measures the unoccupied plasma binding sites for T4 and T3 and thereby provides an indirect assessment of free hormone concentration. A low T3 RU indicates a high binding capacity and is seen in hypothyroidism, pregnancy and estrogen administration. This test is now outdated and clinicians use the TSH instead. Anti-microsomal antibodies (B) and thyroglobulin antibodies are present in autoimmune thyroid states such as Hashimoto´s thyroiditis and Grave´s disease. Serum thyroglobulin (D) is increased in patients with an enlarged thyroid or following acute trauma to the thyroid. Thyroglobulin determinations are most useful in the follow-up of patients with metastatic thyroid carcinoma following thyroidectomy. Reverse T3 (E) derives from the peripheral metabolism of T4 to T3. Its measurement is not generally useful clinically.

Explanation:

Diabetic nephropathy can eventually progress to end stage renal disease. A low sodium diet is useful to control essential hypertension and its consequence, but not to prevent diabetic nephropathy from progressing. The DCCT trail has shown that tight control of diabetes and glucose control can slow down the progression of renal dysfunction in a type I diabetics. ACE inhibitors such as captopril can vasodilate the afferent arteroiles in the kidneys and thus prevent glomeruler hypertrophy and also decrease the perfusion pressure. Radiocontrast dye used in certain tests can cause interstitial damage and thus damage the kidneys further. Other nephrotoxic drugs, such as aminoglycosides, should be used carefully in a diabetic with nephropathy.

Explanation:

Secondary hypogonadism, not primary hypogonadism, is associated with a deficiency of gonadotropin releasing hormone from the hypothalamus or a deficiency of LH and FSH from the pituitary gland. Secondary hypogonadism can be due to pituitary adenoma, craniopharyngioma, or intracranial radiation. Serum LH and FSH levels are elevated in primary hypogonadism because of the lack of testosterone production in the gonads. Serum testosterone levels are low secondary to decreased production in the scrotum. Lack of testosterone can lead to a decrease in erythropoiesis, osteoporosis, and muscle mass. Lifelong androgen replacement in the form of intramuscular testosterone and transdermal testosterone patches are needed in primary hypogonadism.

Explanation:

Explanation:

Hyperparathyroidism does not decrease release of calcitonin. If the biofeedback loop is operant, one would expect an elevation of calcitonin in hyperparathyroidism. Increased absorption of calcium in the intestine, decreased excretion by the kidneys, increased release of calcium from bone, and hypophosphatemia all result from hyperparathyroidism.

Explanation:

A compliant young patient with brittle diabetes requiring frequent doses of insulin, who is still not under good control, is a good candidate for an insulin pump that provides a continuous dose of insulin. None of the other interventions would be appropriate in this patient at this time.

Explanation:

Paroxysmal hypertension in an adult should lead to suspicion of a pheochromocytoma, which produces catecholamines. This is easily detected by a 24 hour urine collection for catecholamines. Serum aldosterone levels would not be affected, nor would serum angiotensin-converting enzyme levels, urine sodium, or serum ACTH.

Explanation:

The patient´s symptoms are consistent with primary hypothyroidism due to a goiter. The biofeedback regulation of the thyroid would lead to elevated TSH levels in an attempt by the pituitary to compensate for the lack of thyroxine production by the thyroid. This condition is not associated with any of the other answer choices.

Explanation:

Lactic acidosis, characterized by elevated blood lactate, decreased arterial blood pH, decreased bicarbonate, and electrolyte imbalances with an elevated anion gap (normal= 10-12), is a rare but serious complication of metformin administration. The onset of lactic acidosis is usually accompanied by several nonspecific signs and symptoms, including malaise myalgias, respire to distress, and increased somnolence. There may be associated hypothermia, hypotension, and resistant bradyarrhythmias as the condition progresses. When this condition occurs, it is fatal in approximately 50% of cases. Metformin should not be used in patients with renal insufficiency, heart failure, conditions predisposing to hypoxemia, or lactic acidosis. Glucagon is a polypeptide hormone produced by the alpha cells of the islets of Langerhans in the pancreas. It stimulates the conversion of glycogen to glucose in the liver. This hormone is available commercially to be administered in an intramuscular injection for the emergency treatment of severe hypoglycemia in diabetic patients when the administration of oral glucose is not possible. The most common adverse effects include pain at the site of the injection as well as hyperglycemia. Glyburide is a sulfonylurea associated with the development of hypoglycemia and cholestatic jaundice. Miglitol is an alpha-glucosidase inhibitor commonly associated with the development of abdominal discomfort and flatulence. Repaglinide is the non sulfonylurea moiety of glyburide; it is commonly associated with hypoglycemia, nausea, and vomiting.

Explanation:

Osteopaenia is defined as a T score of´ between -1 and -2.5 standard deviations below the bone mineral density of a young female. Osteoporosis is defined as <-2.5 SD. These measurements are important as they signify a greatly increased risk of fracture. Z scores to the bone mineral density compared with that of a ´normal´ age matched subject.

Explanation:

The consensus authors state that ability to achieve and maintain glycaemic control is the most important factor when selecting between diabetes therapies, with:
-safety
-tolerability
-Side-effects
-ease of use and
-expense
being other factors of importance.

Explanation:

Whilst the consensus authors acknowledge the problem of lactic acidosis, with an incidence of 1 in 100,000, they also talk about the fact that metformin is likely to be safe to lower levels of glomerular filtration rate (GFR) than previously thought.
They cite studies suggesting that it is safe down to a GFR of 30 ml/min, as such the calculated GFR of 38 here suggests that metformin may be continued, at least for the moment.

Explanation:

Intensive diet and lifestyle advice with metformin started concurrently is the consensus recommendation. Some confusion here may come from the fifth option above, referral for bariatric surgery. Whilst the authors acknowledge that bariatric surgery may be associated with weight loss of 20 kg or more, and reversal of metabolic abnormalities, they stop short of making a recommendation qualified by body mass index (BMI) in the guidelines. Whilst acarbose may result in a small degree of weight loss and modest reduction in HbA1c, metformin is recommended ahead of it. Pioglitazone causes weight gain and increases the risk of bone fracture-as such it would not be recommended as initial therapy here.

Explanation:

21 hydroxylase is the enzyme involved in the cholesterol steroid pathway and has been found to be present in approximately 80% of case.

Explanation:

The quinolones have recently been associated with tendon rupture. Rupture has been reported in the Achilles, shoulder and hand. This may occur due to disruption of the extracellular matrix and depletion of collagen which is observed in animal models. Aripiprazole is a second generation antipsychotic, and exenatide is glucagon like-peptide 1 analogue used in the management of Type 2 diabetes. Neither of these products has been associated with tendon rupture.

Explanation:

Her symptoms are suggestive of postural hypotension, which together with hyperkalaemic (and hyponatraemia) acidosis would strongly indicate the presence of Addison´s disease. Cushing´s and Conn´s syndromes are associated with hypertension and hypokalaemia. Hypokalaemia is the most frequent complication of bulimia which may cause cardiac arrhythmias, fits and paraesthesia. Renal tubular acidosis (RTA) is due to inability of the renal tubules to maintain acid-base balance, causing a hyperchloraemia and a normal anion-gap. In type 1 (distal) RTA; there is hypokalaemic acidosis with low urinary ammonium production. Patients present with hyperventilation/acidosis and muscular weakness from hypokalaemia. In type 4 RTA (hyporeninaemic hypoaldosteronism), there is hyperkalaemic acidosis caused by chronic renal insufficiency from diabetes or tubulointerstitial disease.

Explanation:

This obese male has sub-optimal control of his hyperglycaemia (HbA1C 7.4%) despite diet. One should aim for HbA1C below 7% and so the addition of metformin would be the most appropriate choice for this man.

Explanation:

This man has galactorrhoea and raised prolactin. The most likely culprit is metoclopramide through its action on dopamine. It releases prolactin through dopamine antagonism.

Explanation:

This patient has diabetic nephropathy with marked proteinuria. To attenuate the progression towards end stage renal disease, stringent blood pressure control should be employed maintaining a BP less than 130/80 mmHg and an angiotensin-converting enzyme (ACE) inhibitor would probably offer even greater reno-protection than any other antihypertensive. Simvastatin has no proven benefit on renal disease and improved glycaemic control although of benefit would be of less benefit than BP control (UKPDS/DCCT trials). Again stopping smoking would probably be of greatest benefit to her with regard to reducing cardiovascular risk but would not itself offer any reno-protective effect.

Explanation:

Coeliac disease is the likely option as this patient has autoimmune disease (T1DM), an iron deficiency anaemia and little in the why of symptoms. Bacterial overgrowth is associated with profuse diarrhoea and a macrocytosis due to vitamin B12 consumption. Crohn´s disease again would be expected to be symptomatic.

Explanation:

A pheochromocytoma is a catecholamine secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine products in blood or urine. Imaging tests, especially CT or MRI, help localize tumors. Treatment involves removal of the tumor when possible. Drug therapy for control of BP includes β-blockade, possibly combined with α blockade .

Explanation:

Vitiligo is a loss of skin melanocytes that causes areas of skin depigmentation of varying sizes. Cause is unknown, but the condition may be autoimmune, as up to 1/3 of patients have evidence of other autoimmune disease. Vitiligo affects 0.5 to 2% of the population. Etiology is unknown, but melanocytes are lacking in affected areas; some patients have antibodies to melanin. Up to 30% have other autoimmune antibodies (to thyroglobulin, adrenal cells, and parietal cells) or clinical autoimmune endocrinopathies (Addison´s disease. diabetes mellitus, pernicious anemia, and thyroid dysfunction), leading to speculation that vitiligo is an autoimmune disease. However, the relationship is unclear and may be coincidental. The strongest association is with hyperthyroidism (Graves´ disease) and hypothyroidism (Hashimoto´s thyroiditis).

Explanation:

Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms are many but include tachycardia, fatigue, weight loss, and tremor. Diagnosis is based on history, physical examination, and thyroid function tests. Serum TSH is the best test, because TSH is suppressed in hyperthyroid patients except when the etiology is a TSH-secreting pituitary adenoma or pituitary resistance to thyroid hormone. Free T4 is increased.

Explanation:

Secondary hyperaldosteronism is characterized by sodium retention, and thus decreased urinary sodium excretion, while potassium secretion is normal to increased.

Explanation:

Thyrotoxic crisis is a medical emergency and is an exagerated thyrotoxocosis or thyroid storm. Thyroxine would worsen the condition, but iodide will block thyroid hormone secretion. Cooling blankets help lessen the hyperpyrexia, and hydrocortisone is useful in the management of the stress and relative adrenal in-sufficiency. Propythiouracil inhibits the synthesis of thyroid hormone.

Explanation:

A low caloric intake not only interferes with the nutritional needs of a young and growing organism, but also interferes with the homeostatic mechanisms necessary to maintain functioning. Undernutrition and weight loss associated with anorexia nervosa either reverse pubertal changes and prevent menarche from occurring (primary amenorrhea) or regress the hyperthalamo-pituitary-gonadal axis to prepubertal regulation, resulting in low LH, low FSH and minimal estrogen and progesterone plasma levels (secondary amenorhhea).

Explanation:

Maturity onset of diabetes in the young must be differentiated from juvenile onset diabetes (or insulin dependent diabetes mellitus). IDDM is an autoimmune disorder in which anti islet cell antibodies and T cells reactive with islet cell antigens destroy beta cells within the islets. Mature onset of diabetes in the young, or MODY, is similar to non insulin dependent diabetes except that it occurs in children. Therefore, as with IDDM, the protein that is thought to be defective is the glucokinase cell surface protein.

Explanation:

Ectopic production of thyroid hormones caused by conditions such as an ovarian teratoma result in thyrotoxicosis. Primary hypothyroidism accounts for more than 90% of the cases of hypothyroidism. Autoimmune destructive processes, such as Hashimoto´s thyroiditis or Grave´s disease, eventually result in hypothyroidism. Drugs, such as lithium and sulfonamides, which interfere with thyroid hormone biosynthesis, also result in the condition. Secondary hypothyroidism results from deficient pituitary thyrotrophs. Conditions, such as neoplasms, surgery or Sheehan´s syndrome, which result in panhypopituitarism, cause hypothyroidism. Hypothalamic hypothyroidism, due to decreased TRH secretion, leads to decreased secretion of TSH. Conditions, such as sarcoidosis, which may infiltrate the hypothalamus, or infectious processes, may also lead to hypothyroidism.

Explanation:

The thyroid disease is Hashimoto thyroiditis, an autoimmune disease in which the thyroid parenchyma is destroyed by a lymphocytic infiltrate. The infiltrate typically contains mature follicles; the remaining scanty follicular cells often have eosinophilic granular cytoplasm and are called Hurthle cells or oncocytes. Clinically, patients usually have hypothyroidism although brief periods of hyperthyroidism (“Hashitoxicosis”) may also be seen. Like myasthenia gravis, Hashimoto disease maybe associated with thymic disorders including thymic hyperplasia, benign thymomas, and malignant thymomas. Colon cancer is associated with ulcerative colitis and adenomatous polyps. The risk of esophageal cancer is increased with Barrett esophagus and in Plummer Vinson syndrome. Associate neurofibromas of peripheral nerve with café-au-lait spots on the skin. Skin cancer occurs with greater frequency in association with xeroderma pigmentosa and actinic keratosis.

Explanation:

The most likely diagnosis is diabetic ketoacidosis, especially in the setting of at least one missed insulin dose and an intercurrent illness. Hyperosmolar coma is much less likely in this setting. Hypoglycemic coma is unlikely because of the full insulin syringe. There is no evidence of head trauma or other cause of cerebral hemorrhage. Lactic acidosis is unlikely in this setting.

Explanation:

In the normal 120 day life span of the red blood cell, glucose molecules join hemoglobin, forming glycated hemoglobin. In individuals with poorly controlled diabetes, increases in the quantities of these glycated hemoglobins are noted. Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated hemoglobin within the red cell reflects the average level of glucose to which the cell has been exposed during its life cycle. Measuring glycated hemoglobin assesses the effectiveness of therapy by monitoring long-term serum glucose regulation. The International Diabetes Federation recommend HbA1c values below 6.5%, while the American Diabetes Association recommends that the HbA1c be below 7.0% for most patients. A high HbA1c represents poor glucose control. Persistent elevations in blood sugar (and therefore HbA1c) increase the risk for the long-term vascular complications of diabetes such as coronary disease, heart attack, stroke, heart failure, kidney failure, blindness, erectile dysfunction, neuropathy (loss of sensation, especially in the feet), gangrene, and gastroparesis (slowed emptying of the stomach).

Explanation:

Primary hyperparathyroidism results in hypercalciuria, which raises the urine super saturation of calcium phosphate and/or calcium oxalate. Hyperuricosuria probably induces stone formation by heterogeneous nucleation of calcium oxalate by crystals of sodium hydrogen urate or uric acid. Distal renal tubular acidosis prevents the establishment of a normal pH gradient between urine and blood. The resulting alkalotic urine, associated with hypercalciuria and a low urine citrate level, cause a supersaturation with calcium phosphate, predisposing to calcium phosphate stone formation. Fat malabsorption caused by conditions such as jejunalileal bypass, ileal resection, or chronic diseases of the pancreas, results in overabsorption of dietary oxalate. Hyperoxaluria leads to tubulointerstitial nephropathy and stone formation. Idiopathic hypercalciuria is the most frequent abnormality found in patients with a family history of nephrolithiasis and is associated with an increase in intestinal calcium absorption.

Explanation:

A decrease in both serum T4 and TSH could result from either a pituitary defect or a hypothalamic defect. In the case of the hypothalamic defect (tertiary hypothyroidism), decreased secretion of TRH leads to decreased TSH secretion and hence, decreased T4 secretion. In secondary hyperthyroidism, a decrease in TSH secretion due to a pituitary defect (e.g., by tumors, radiation surgery, Sheehan syndrome, empty sella syndrome) is responsible for the decreased T4. The TRH stimulation test can be used to distinguish between these two possibilities. Failure of TSH to increase after injection of TRH indicates a pituitary detect. Hashimoto thyroiditis is an autoimmune disease that leads to primary hypothyroidism (low serum T4) and increased serum TSH. The autoantibodies ultimately lead to thyroid failure and decreased secretion of thyroid hormones. The decrease in negative feedback at the hypothalamus and pituitary leads to increased secretion of TSH.

Explanation:

The correct answer is C. Features of papillary carcinoma of the thyroid on aspiration include papillary clusters, “Orphan Annie” nuclei, and psammoma bodies. Psammoma bodies are laminated, concentric, calcific spherules seen most frequently in papillary adenocarcinoma of the thyroid, serous papillary cystadenocarcinoma of the ovary, meningioma, and malignant mesothelioma. Anitschkow cells are activated histiocytes found in rheumatic heart disease. Auer rods are cytoplasmic inclusions found in promyelocytic leukemia cells. Reed Sternberg cells are typically binucleate (or contain bibbed nuclei) with prominent “owl´s-eye” nucleoli cells, found in Hodgkin disease. Roth´s spots are pale retinal spots surrounded by hemorrhage, seen in endocarditis.

Explanation:

Type 1 diabetes mellitus most commonly occurs in children secondary to decreased blood insulin levels. In type 1 diabetes the lack of insulin production is caused by an autoimmune mediated destruction of insulin producing beta cells. As a result of this autoimmune process1 patients with type 1 diabetes generally have circulating islet cell antibodies, which include anti-glutamic acid decarboxylase (anti-GAD) antibodies. Furthermore this condition is linked to HLA types DR3, DR4, and DR3/4. The only FDA-approved treatment measure for type 1 diabetes mellitus is insulin. Metformin is indicated for the treatment of type 2 diabetes mellitus. Type 2 diabetes is not an autoimmune process and would therefore not be HLA-linked or be associated with the presence of islet cell antibodies. Amphetamine salts are commonly used in the treatment of ADD (attention deficit disorder) and ADHD (attention deficit hyperactivity disorder) in children. Captopril is an ACE (angiotensin-converting enzyme) inhibitor commonly used in the treatment of heart failure and hypertension.

Explanation:

This patient has gynecomastia, which is most likely due to his testosterone intake. Testosterone is converted to estradiol in extraglandular tissues and leads to feminization. Gynecomastia is yew common in adolescents during puberty and is frequently asymmetric and tender. It usually regresses before age 20. Evaluation for liver disease is unnecessary at this point because the gynecomastia is most likely due to his testosterone usage or to puberty. He has no other signs of liver disease. Fine needle aspiration and mammography are used to evaluate a dominant breast mass or possibly gynecomastia in a patient who is not going through puberty who has a negative drug history or who has a rapidly growing, large (>4-cm) mass. This patient has explanations for gynecomastia (testosterone and puberty), making further workup too aggressive at this time. Reassurance would be the appropriate answer if this boy were not taking testosterone.

Explanation:

This patient is more than likely to be GH deficient which would explain the lethargy but this requires confirmation before initiating treatment. Although an insulin tolerance test is the gold standard for the diagnosis of GHD, it is contra-indicated due to the epilepsy• Therefore GHRH/arginine is regarded as a suitable alternative.

Explanation:

The short acting Insulin analogue, Lispro has a rapid onset of action and a shorter duration of action than conventional short acting soluble insulin´s. Consequently studies reveal reduced post prandial glucose concentrations versus soluble insulin and potentially a reduced incidence of hypoglycaemia although the evidence for this is lacking.