GENERAL PRACTITIONER EXAM
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Question 1 of 13
1. Question
1 pointsA 60 year old woman with advanced metastatic lung cancer develops profound fatigue and weakness and alternating diarrhea and constipation. Physical examination reveals hyperpigmentation of skin even in areas protected from the sun. This patient´s presentation suggests tumor involvement of which endocrine organ?
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Explanation:
This is Addison disease, in which severe adrenal disease produces adrenocortical insufficiency. Causes include autoimmune destruction, congenital adrenal hyperplasia, hemorrhagic necrosis and replacement of the glands by either tumor (usually metastatic) or granulomatous disease (usually tuberculosis). The symptoms can be subtle and nonspecific (such as those illustrated) so a high clinical index of suspicion is warranted. Skin hyperpigmentation is a specific clue that may be present on physical examination suggesting excess pituitary ACTH secretion. (The ACTH precursor has an amino acid sequence similar to MSH, melanocyte stimulating hormone.) Most patients have symptoms (fatigue gastrointestinal distress) related principally to glucocorticoid deficiency. In some cases however mineralocorticoid replacement may also be needed for symptoms of salt wasting with lower circulating volume. Except in the case of primary pancreatic cancer, complete tumor replacement of the endocrine pancreas would be uncommon. In any event pancreatic involvement would be associated with diabetes mellitus. Involvement of the ovaries by metastatic tumor (classically gastric adenocarcinoma) would produce failure of menstruation. Involvement of the pituitary gland could produce addisonian symptoms but the pigmented skin suggests a prima adrenal problem rather than pituitary involvement. Replacement of the thyroid gland by tumor would cause hypothyroidism with lesser degrees of fatigue and cold intolerance; this is an unusual cause of hypothyroidism and is less likely to be tested than Addison disease caused by bilateral adrenal metastasis.
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Question 2 of 13
2. Question
1 pointsCalcitonin is synthesized by which of the following cell types?
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Explanation:
Calcitonin is synthesized by the C cells of the thyroid, not by any of the other cells listed. Sertoli cells secrete androgen-binding protein, inhibin, and MIS (mullerian inhibiting substance). Leydig cells secrete testosterone. Langerhans cells secrete insulin. Pituitary chromophobes are resting (nonsecretory) cells.
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Question 3 of 13
3. Question
1 pointsA 30 year old male with type I diabetes mellitus presents with confusion, weakness, polyurea, and polydipsia. His blood glucose was 610 mg/dl. Blood pH was found to be 7.24. Diabetic ketoacidosis is suspected. Which of the following criteria can NOT be used to diagnose diabetic ketoacidosis?
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Explanation:
Most patients with DKA present with high white blood cell counts without a left shift. If the leukocytosis is greater than 25,000/mL, a bacterial infection should be suspected as a predisposing cause for DKA. Hyperglycemia in diabetics increases the risk for diabetic ketoacidosis. It increases serum osmolality and overproduction of glucose by the liver leads to impaired glucose utilization by peripheral tissues. Lack of insulin production by the beta cells of the pancreas leads to diabetic ketoacidosis in type I (insulindependent) diabetics. Patients with diabetic ketoacidosis have a high anion gap (greater than 12) metabolic acidosis secondary to decreases in serum bicarbonate levels. Nitroprusside detects serum ketones which are elevated in DKA. Ketonemia is caused by beta hydroxybutyrate and acetoacetic acid levels greater than 3 mmol/L. Infection, trauma, stroke, pancreatitis, lack of adequate insulin, and steroid therapy all are precipitating factors which can cause diabetic ketoacidosis. Bicarbonate levels less than 15 meq/L cause metabolic acidosis, which is seen in DKA.
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Question 4 of 13
4. Question
1 pointsA 42 year old male develops polyuria and polydipsia with normoglycemia and no glycosuria. The laboratory test that is most likely to be diagnostic is which one of the following?
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Explanation:
This patient appears to have diabetes insipidus, which could be diagnosed by a vasopressin immunoassay Abnormalities in the glucose tolerance test would not be expected in the absence of hyperglycemia and glycosuria. Abnormalities in prolactin, liver enzymes, and urine free cortisol also would not be likely in this setting.
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Question 5 of 13
5. Question
1 pointsIn nondiabetics, hypoglycemia does NOT result from which of the following?
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Explanation:
Causes of hypoglycemia in nondiabetics may also produce hypoglycemia in diabetics. A wide variety of drugs may produce hypoglycemia. Alcohol inhibits hepatic gluconeogenesis. Hypoglycemia occurs when hepatic gluconeogenesis is the main source of glucose production, such as during periods of starvation. Insulin and oral hypoglycemics may produce hypoglycemia when these drugs are used surreptitiously for ulterior motives. In addition to insulinomas, non beta cell tumors may produce hypoglycemia. These tumors suppress plasma insulin levels and, in some cases, induce hypoglycemia through massive glucose utilization. Reactive, postprandial hypoglycemia occurs in persons with rapid gastric emptying, such as following a gastrectomy. Rapid absorption of glucose stimulates brisk insulin release, leading to inappropriately elevated insulin levels. Cushing´s syndrome results from glucocorticoid excess. Hyperglycemia is a characteristic feature.
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Question 6 of 13
6. Question
1 pointsA 56 year old type 1 diabetic male presents to the emergency department after experiencing severe diarrhea for the past 5 days. Investigation reveals the following: - Metabolic acidosis with a normal gap
- Potassium level of 3.2mEq/L
- Urine pH of 5.1
Which would increase the urine pH but worsen the hypokalemia and acidosis?
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Explanation:
There are two basic types of acid-base disorders. They are respiratory (affecting the blood pH by causing changes in PCO2) and metabolic (affecting the blood pH by causing changes in HCO3). Acetazolamide is an oral medication that inhibits the enzyme carbonic anhydrase, leading to a reduction of aqueous humor production and a subsequent decrease in intraocular pressure (IOP). This agent is indicated for the prompt lowering of IOP in patients with glaucoma as well as adjunct treatment of edema caused by heart failure and epilepsy. Acetazolamide is contraindicated for use in patients with hypokalemia, hyponatremia, metabolic acidotic states, as well as severe hepatic/renal dysfunction. In contrast to diarrhea, which causes the development of acidic urine, acetazolamide produces alkaline urine. The reason that acetazolamide causes acidosis is that inhibition of carbonic anhydrase is associated with a rapid rise in urinary HCO3 excretion to approximately 35% of filtered load. This along with inhibition of titratable acid and NH4+ secretion in the collecting duct system results in an increase in urinary pH to approximately 8 and development of metabolic acidosis. Acetazolamide causes hypokalemia because the fractional excretion of Na may be only 5% and the fractional excretion of K can be upto 70%. The increased excretion of K+ is, in part, secondary to increased delivery of Na to the distal nephron. Other mechanisms contributing to enhanced K+ excretion include flow-dependent enhancement of K+ secretion by the collecting duct, nonosmotic vasopressin release, and activation of the renin-angiotensin-aldosterone axis. The administration of antacids (large amounts), sodium bicarbonate and diuretics, such as furosemide would lead to the development of metabolic alkalosis or help to correct the patient´s metabolic acidosis. Remember sodium bicarbonate and antacids are basic substances and would be expected to help correct the patient´s metabolic acidotic state. With respect to loop diuretics such as furosemide, these agents increase salt delivery to the collecting duct. Increased delivery leads to increased secretion of K+ and H+ by the duct, causing hypokalemic metabolic alkalosis. This toxicity is a function of the magnitude of the diuresis and can be reversed by K+ replacement and correction of hypovolemia. Respiratory acidosis is often seen in patients with chronic lung diseases, and when opioid analgesics such as hydrocodone, oxycodone, and morphine are administered in large doses. In these patients, the potassium level would not be affected. Theophylline administration is sometimes associated with the development of respiratory alkalosis. Theophylline does not affect a patient´s potassium level.
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Question 7 of 13
7. Question
1 pointsA 49 year old female has complaints of moderate weight loss over the past 6 months, heat intolerance, palpitations, and fine tremors in the hands. Examination shows diffuse goiter and exophthalmos. Which lab finding would be expected in her?
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Explanation:
The description given here is of an individual with Graves disease. Hypersecretion of thyroid hormone because of stimulation of the TSH receptor by thyroid stimulating immunoglobulins results in excessive movement of thyroglobulin from the colloid to the plasma. The presence of exophthalmos is thought to be part of the autoimmune disorder in Graves disease. It is postulated that the thyroid and orbital muscles may share a common antigen. Lymphocytic infiltration and inflammation of orbital muscle then produces the ophthalmopathy. Serum T4 is increased in Graves disease. Because of excessive stimulation of the thyroid by the thyroid-stimulating immunoglobulins, radioactive iodine uptake, which assesses iodine trapping, is increased. The increase in free T4 due to hypersecretion by the thyroid shifts the equilibrium between free and bound T4 toward an increase in thyroxine binding globulin (TBG) bound hormone. Concomitantly, the concentration of unbound TBG falls. Hence, the radioactive T3 in the resin T3 uptake test would preferentially bind to the resin and resin uptake would be increased (not decreased). The increased plasma levels of T4 will feed back to the hypothalamus and pituitary and decrease the secretion of TSH (not increase it). In Graves disease, TSH is not controlling the thyroid gland; thyroid stimulating immunoglobulins take over this function.
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Question 8 of 13
8. Question
1 pointsA 32 year old man presents has complaint of inability to impregnate his wife. He wants to find out if he is infertile. He denies fatigue and states that he has a decreased libido. On exam, his testes appear normal. Lab testing would likely reveal that in addition to a low sperm count he has elevated level of which hormone?
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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.
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Question 9 of 13
9. Question
1 pointsA 74 year old female is diagnosed with Cushing´s disease. The correct statement is which one of the following?
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Explanation:
Transphenoidal hypophysectomy/ adenomectomy would be the initial treatment of choice. Laparoscopic adrenalectomy would be advised where pituitary surgery has failed. Ketoconazole may be an effective treatment for patients unfit for surgery.
OpDDD is used for adrenal carcinomas. Yttrium implantation has been abandoned even for acromegaly as it is pretty useless. A The recurrence rate for Cushing´s disease after surgery is of the order of 20-30% in most series and depends on the size of the tumour with macroadenomas having a higher rate of relapse. -
Question 10 of 13
10. Question
1 pointsA chromophobe adenoma of the pituitary would be expected in which of the following condition?
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Explanation:
A chromophobe adenoma refers to no uptake of dye within the tumourous specimen. This occurs in the non-secretory/non-functioning pituitary tumours.
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Question 11 of 13
11. Question
1 pointsA 31 year old female with long standing Type I diabetes presents with a 3 month history of pain and stiffness of the right shoulder. Active and passive movements of the shoulder are equally restricted. The most likely diagnosis is
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Explanation:
Adhesive capsulitis (frozen shoulder) is strongly associated with diabetes with as many as 40% of patients developing this problem at some stage. The restricted active and passive movements confirm that this patient´s problems are either capsular or articular in origin rather than periarticular tendon problems where active movements are generally more restricted than passive movements.
The shoulder joint is rarely affected by primary osteoarthritis. -
Question 12 of 13
12. Question
1 pointsA 21 year old female has a 5 year history of hirsutism with her having noticed coarse dark hair under her chin. Her periods are irregular. She has not yet conceived and has had a coil fitted for contraception. She has coarse, dark hair over her chin, lower back and inner thighs. No galactorrhea or features of cushing´s disease are present. Labs during the follicular phase show serum 17-hydroxyprogesterone 18.6pmol/L(1-10), oestradiol of 380 pmol/L (200-400), testosterone of 2.6 nmol/L (0.5-3), LH of 3.3 U/L (2.5-10), and FSH of 3.6 U/L (2.5 -10). The next appropriate investigation is
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Explanation:
In this case the patient has features that would suggest polycystic ovary syndrome (PCOS) yet the 17OHP concentration is elevated and is compatible with non-classical congenital adrenal hyperplasia (CAH) yet just below the threshold of 33nmol/L confidently to make the diagnosis. Thus a short Synacthen test would be the most appropriate investigation with measurement of 17OHP. A rise in 17OHP above 33nmol/L suggests non classical CAH.
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Question 13 of 13
13. Question
1 pointsA 49-year-old hypertensive has shooting pains in his hands worse at night. He has gained a great deal of weight over the past couple of years. His appearance is changing with time. He has increased thirst and urination. There is out of proportion enlargement of the hands and feet. What test to be conducted first?
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Explanation:
This patient has acromegaly, which is an excess of growth hormone. This is evidenced by increased hand and foot size and coarse facial features with protruding jaw. Other features, including tooth space widening and macroglossia, can present with acromegaly. Impaired glucose tolerance often exists, as does diabetes. Hypertension is present in one-third of patients with acromegaly.
Complaints of headache and visual fields loss can occur. Patients may have carpal tunnel syndrome. The test or choice to diagnose this condition is insulin-like growth factor, which is elevated to 5 times the upper limit of normal. Another test to be used to diagnose acromegaly is measurement of growth hormone after administration of 100 grams or glucose. In healthy patient the growth hormone level would be suppressed, whereas the levels in patient >5 times the upper limit of normal. Another test that could be used to diagnose acromegaly is to obtain a growth hormone level after the administration of glucose 100 g. In a healthy patient the growth hormone level would be suppressed, whereas in a patient with acromegaly, the level would remain high (1.e., >5 ng/mL).
Cortisol level might be helpful in diagnosing Cushing´s syndrome, which can also be associated with insulin resistance, hypertension, and weight gain. However, Cushing´s syndrome does not Share other features associated with acromegaly, CT scan of the brain would likely reveal a pituitary macroadenoma. A CT scan (or other imaging technique) should be performed to confirm most endocrine disorders only after they are suggested serologically. This is to avoid diagnostic errors that can be made with the presence of tumors discovered incidentally. The presence of such tumors, which are Unrelated to the patient´s condition, could potentially lead the Clinician down an incorrect course.
Cushing´s syndrome can be associated with insulin resistance, hypertension, and weight gain but doesn´t share other features associated with acromegaly.
CT scan of the brain would likely reveal a macroadenoma in this patient. A CT scanning (or other imaging technique) should be conducted to confirm most endocrine disorders only after they are suggested serologically. This is to avoid diagnostic errors that can be made due to the presence of tumors incidentally discovered that are unrelated to the patient´s condition and potentially lead the clinician to an incorrect diagnosis and course of treatment.
Fasting glucose level is the best screening test for diabetes. It is likely that the patient has diabetes secondary to acromegaly, evidenced by polyuria and polydipsia. It is appropriate to measure fasting glucose levels in this patient but it is not the test to use to diagnose the patient´s underlying medical problem.
Growth hormone levels should not be used as a screening mechanism to diagnose acromegaly because gonadotropin-releasing hormone and growth hormone fluctuate normally throughout the day. Exercise, or even acute illness, can contribute to such fluctuations. Falsely elevated growth hormone levels, therefore, can be found in patients with normal growth hormone levels. Similarly, patients with acromegaly can have false normal growth hormone levels.