Philip Kelly

AÿEIQ rons
Book 7
Cardiology
Respiratory- Dermatology
Medicine
Endocrinology
& Metabolism
Gastroenterology
Psychiatry
RenalMedicine

PASTEST
Dedicated to your Success
Contributors vii
Acknowledgements viii
Introduction ix

Dermatology 1
Questions 3

Endocrinology and Metabolism 19

Questions 21

Gastroenterology 65
Questions 67

Psychiatry 11 1
Questions 113

Renal Medicine 121

Questions 123

Answers with teaching explanations 145

Dermatology 146
Endocrinology and Metabolism 1 58
Gastroenterology 187
Psychiatry 213
Renal Medicine 219

Index 225

v
Dermatology
Virginia Hubbard MBBS MRCP
Consultant Dermatologist, The Whittington Hospital, London.
Endocrinology and Metabolism
Philip Kelly MBBS MRCP
Department of Diabetes and Metabolism, Royal London Hospital,
London.
Gastroenterology
Peter Irving MA MRCP
Specialist Registrar in Gastroenterology, Whipps Cross University
Hospital, London.
Psychiatry
Neil Harrison MRCP MRCPsych
Clinical Research Fellow, Institute of Cognitive Neuroscience and
Honorary Specialist Registrar, Neuropsychiatry, National Hospital,
Queen Square.
Renal Medicine
Ravi Rajakaria BSc(Hons) MBChB MRCP
Experimental Medicine and Nephrology, William Harvey Research
Institute, London.

vii
 I would like to express my gratitude to the team al PasTest particularly
Amy Smith and Cathy Dickens for their unswerving support and tolerance
during the preparation of this book and series. Many patients have been
gracious enough to contribute to our ongoing education by allowing their
images to be used in these volumes. The series would have been
impossible without the help of the following: Dr Ed Seward, The
Middlesex Hospital, London for his comments on the gastroenterology
chapter; Drs. S Whitely, N Power and O Chan, Radiology; Dr R Feakins,
Pathology; Dr R Marley, Hepatology, BartsandThe London NHS Trust; Dr
R Makins, Homerton University Hospital NHS Trust and Dr J Mawdsley,
Barts and The London, Queen Mary School of Medicine and Dentistry;
Medical Photography, Radiology and Medicine, King George Hospital,
llford; Medical Illustration at Barts and The London School of Medicine
and Dentistry and The Department of Diabetes and Metabolism at The
Royal London Hospital. Special thanks are due to Dr Alexandra Nanzerfor
her considered and helpful criticisms and delightful encouragement.

Philip Kelly

VII
The MRCP (UK) Part 2 written examination consists of two 3-hour papers,
each with up to 100 multiple choice questions; they are either one from
five (best of 5) or 'n' from many, where two answers are chosen from ten.
Each question will have a clinical scenario and might contain
investigations to interpret; many might also contain an image. There is a
pass-mark agreed by the examiners but a candidate's performance is also
assessed in relation to other candidates.
This three-book series provides practice questions with extensive
explanations to aid candidates preparing for the examination. The authors
are all clinicians writing sections in their chosen fields and as such have
been chosen for their clear understanding of the required knowledgebase
for this important exam. The breadth of knowledge for this exam is vast
and they have attempted to cover the 'syllabus' as completely as possible.
Great care has been taken to explain areas that cause difficulty as
thoroughly as possible. No apology is made where the format of the
questions differs slightly from the exam. These books are not merely
practice papers but educational aids and where a topic can be best
explained by diversion from the strict format of the exam, for the sake of
understanding, this has been done.
This book covers dermatology, endocrinology and metabolism,
gastroenterology, psychiatry, and renal medicine and is best taken - in
concert with its partners within the series - as a supplement to a thorough
clinical grounding, the general medical texts and the core clinical
journals.
Any comments or suggestions on this book or the series will be gratefully
received.

ix
 DERMATOLOGY - QUESTIONS

Case 1
-4 42-year-old woman presented with a 6-month history of this
appearance:

1 Which of the following would not be associated with this appearance?

ÿ A Radiolucent bone cysts on a plain X-ray of the hands
ÿ B Hypocalcaemia
ÿ C Symmetrical polyarthropathy involving the small joints of the hands
ÿ D Mikulicz syndrome
ÿ E Restrictive pattern on pulmonary function tests

3
DERMATOLOGY - QUESTIONS

Case 2

This 32-year-old woman presented with hair loss for 8 months.

1 Which of the following would typically cause this pattern of hair loss?
ÿ Discoid lupus erythematosus
A
ÿ Dissecting cellulitis of the scalp
B
C3 C Tinea capitis
O D Hypothyroidism
ÿ E Alopecia areata

4
 DERMATOLOGY - QUESTIONS

Case 3

A 34-year-old man presented with a 3-month history of depigmented

patches over his hands. He says the problem is spreading.

1 Which of the following conditions has an increased incidence in

association with this picture?
ÿ A Lichen planus
ÿ B Hyperparathyroidism
ÿ C Sarcoidosis
ÿ D Pernicious anaemia
0 E Haemochromatosis

5
DERMATOLOGY- QUESTIONS

Case 4

This 67-year-old man with hypertension and epilepsy developed this rash
while on holiday in southern Spain.

1 Which of his drugs is the most likely culprit in this pattern of drug rash?
ÿ A Atenolol
ÿ B Bendroflumethiazide
ÿ C Codeine phosphate
ÿ D Phenytoin
ÿ E Aspirin

6
 DERMATOLOGY - QUESTIONS

Case 5

1 Which of the following is not associated with the appearance of this

tongue?
ÿ A Phenytoin treatment
ÿ B Trisomy 21
D C Crohn's disease
ÿ D Sarcoid
D E Geographical tongue

7
DERMATOLOGY - QUESTIONS

Case 6

A 31-year-old man returned from a holiday in Florida with this rash on his
right shin. The rash spread at a rate of approximately 1cm per day. He was
systemically well.

1 What is the likeliest pathogenic organism?

ÿ A Toxocara canis
ÿ B Schistosoma haematobium
ÿ C Strongyloides stercoralis
ÿ D Sarcoptes scabei
ÿ E Ankylostoma braziliense

8
 DERMATOLOGY - QUESTIONS

Case 7

This 42-year-old woman presented with excess facial hair.

1 Which of the following is not a recognised cause of this appearance?

ÿ A Spironolactone
ÿ B Congenital adrenal hyperplasia (CAH)
ÿ C Polycystic ovary syndrome (PCOS)
ÿ D Cushing's disease
ÿ E Hyperprolactinaemia

9
DERMATOLOGY - QUESTIONS

Case 8

A 38-year-old woman presented with a 6-month history of this appearance

in both axillae. Her BMI was 35.

1 What is the most appropriate first investigation?

ÿ Fasting glucose
A
ÿ CXR
B
ÿ C Skin biopsy
D D Ovarian ultrasound
ÿ E Colonoscopy

10
 DERMATOLOGY - QUESTIONS

Case 9

A 78-year-old woman presents short of breath, with haemoptysis.

1 What is the diagnosis?

ÿ A Lichen planus
ÿ B Dermatomyositis
ÿ C SLE
ÿ D Psoriasis
Zj E Allergic contact dermatitis

11
DERMATOLOGY- QUESTIONS

Case 10

A 31-year-old man with ulcerative colitis had a laparotomy. Three weeks

later the scar broke down, leaving this picture. Microbiology swabs were
negative.

1 What is the most appropriate treatment for this?

ÿ A Broad-spectrum intravascular antibiotics
ÿ B Surgical debridement
ÿ C Pulsed intravenous methylprednisolone
ÿ D Sulfasalazine
C E Intravenous aciclovir

12
 DERMATOLOGY - QUESTIONS

Case 11

A 3 1-year-old engineer returned from a trip to Saudi Arabia 2 months

previously. He presented with a red nodule which subsequently ulcerated
to give this appearance:

1 What is the most likely diagnosis?

D A Mosquito bite
[ ] B Mycetoma
ÿ C Lepromatous leprosy
ÿ D Cutaneous leishmaniasis
ÿ E Lupus vulgaris

13
DERMATOLOGY - QUESTIONS

Case 12

A 38-year-old intravenous drug user presented with a 6-month history of

an itchy rash over his wrists andankles. He was hepatitis C-positive.

1 What is this rash?

ÿ A Eczema
ÿ B Scabies
ÿ C Psoriasis
ÿ D Secondary syphilis
ÿ E Lichen planus

14
 DERMATOLOGY - QUESTIONS

Case 13

A 29-year-old man from Nigeria was admitted to hospital while visiting

relatives in the UK, with a weak right hand. He was also noted to have this
rash.

1 What is the unifying diagnosis?

ÿ A Vitiligo
ÿ B Psoriasis
D C Granuloma annulare
D D Leprosy
ÿ E Tuberculosis

15
DERMATOLOGY- QUESTIONS

Case 14

A 34-year-old woman was referred from the Psychiatric Unit with a

3-week history of a rash. This had started as widespread erythematous
macules, but evolved to the picture below. She had commenced
carbamazepine 1 month previously. She also had a urinary tract infection
and had been started on co-trimoxazole earlier in the week.

1 What is the most important therapeutic intervention?

ÿ AAggressive intravascular antibiotic treatment for urinary sepsis
ÿ BSystemic corticosteroids
ÿ C Withdraw carbamazepine
ÿ D Insertion of a central venous line
ÿ E Cool the body

16
 DERMATOLOGY - QUESTIONS

Case 15

A 54-year-old woman presented with weight loss. These are her hands.
She was ANA-negative.

1 What is the diagnosis?

ÿ A Osteoarthritis
CD B Rheumatoid arthritis
ÿ C Pseudogout
ÿ D Systemic sclerosis
ÿ E SLE

17
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 1

-4 lady is followed up in the clinic with hypothyroidism. Her thyroid

replacement is being titrated andshe is currently taking 50 micrograms
thyroxine once dialy.
On examination she is 85 kg, 1.65 m and the skin is cool and dry. The
pulse is regular, low-volume and 52 bpm, JVP 4 cm, there is no oedema.
The praecordium and lungs are normal. In the abdomen there is 2-cm
hepatomegaly.
The following fasting investigations were performed before clinic:
Plasma glucose 6.0 mmol/L
Cholesterol 13.0 mmol/L
HDL cholesterol 0.8 mmol/L
LDL cholesterol 1 .9 mmol/L
Triglycerides 7.3 mmol/L
On her palms the following appearance is observed:

Wellcome Trust Mcdic.il Photographic Library

1 Which is the most likely diagnosis?

CD A Hyperlipidaemia of diabetes
CD B Familial hypercholesterolemia (type lla hyperlipidaemia)
ÿ C Familial combined hyperlipidaemia (type lib hyperlipidaemia)
LJ D Familial hypertriglyceridaemia (type V hyperlipidaemia)
ÿ E Familial dysbetalipoproteinaemia (type III hyperlipidaemia)

21
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 2

You are referred a lady with thyrotoxicosis and exophthalmos. She has a
moderate sized nodular goitre. The CI' has already started her on
carbimazole and this is her thyroid function while taking 5 mg once daily.
FreeT4 15.1 pmol/L
TSH 2.1 mU/L
Urine p-HCG Negative
She has a neck scan and a CT orbit to assess the exophthalmos:

RT L.T

T
*19 ii
9 THYROID SCON 23 Nov 1988 at 14:59

22
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

1 What is the next step?

Lj A Continue carbimazole, titrating the dose to suppress the TSH to below
the normal range
ÿ B Prednisolone 0.5-1 mg per kg initially for 2-6 weeks
ÿ C Referral to an ophthalmic surgeon
ÿ D Referral to a radiotherapist to consider low-dose lens-sparing orbital
radiotherapy
ÿ E Continue the current medication and consider radioiodine if the goitre
becomes troublesome

23
ENDOCRINOLOGY AND METABOI ISM - QUESTIONS

Case 3

A 27-year-old man is referred with polyuria and thirst. He is on no

medications; there is no family history. Weight 83 kg, height 1.92 m. Ilis
24-hour urine volume is 3 litres.
Urinalysis Ketones +
His 9-am investigations are as follows:
Hb 15 g/d L
WCC llxl07L
Platelets 469 x 107L
Sodium 140 mmol/L
Potassiu m 3.6 mmol/L
Bicarbonate 28 mmol/L
Chloride 1 00 mmol/L
Urea 7.0 mmol/L
Creatinine 1 12 jimol/L
Albumin 46 g/L
Glucose 4.2 mmol/L
Cortisol 300 nmol/L
Tree T4 13.3 pmol/L
TSH 1.2 mU/L
Plasma osmolality 294 mosmol/kg
Urine osmolality 303 mosmol/kg

Time Urine volume Urine Weight (kg) Plasma

in previous osmolality osmolality
hour(mL) (mosmol/kg) (mosmol/kg)
07.30 83
00.00 284
08.30 150 200 82.9
1 1 .00 287
11.30 145 247 82.4
13.30 296 82.0
14.00 292
14.30 140 386 81.5
15.30 145 405 81.2 296
2 p.g DDAVP given intramuscularly
1 6.30 100 570 81.4 29.5
1 7.30 70 912 82.2 288
18.30 40 987 82.8 286
19.30 50 932 82.8 286
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

t Whal is the diagnosis?

ÿ A Nephrogenic diabetes insipidus
ÿ B Polyuric renal failure
LJ C Cranial diabetes insipidus
I D Primary polydipsia
ÿ E None of the above

25
endocrinoi ogy and metaboi ism questions

Case 4

A 60-year-old lady is seen in the clinic for hypercalcaemia. Shortly after

the death of her husband 2 years ago, while being treated for depression,
hypertension was noted; during the investigation of this a corrected
calcium of2.9mmol/L was found, which has persisted. She has been well,
apart from a Colics' fracture 9 years ago sustainedwhen she slipped while
ice-skating with her husband in Manhattan; she does not smoke or drink,
eats a good diet and lives alone with her two greyhounds, one of which
recently had a litter of puppies. She was adopted, did not know her parents
and has no children.
On examination she is 1 67-cm tall, weighs 60 kg, has a blood pressure of
190/90 mmHg, with no postural drop, and no corneal calcification.
Urinalysis is normal.
Her investigations are:
FBC Normal
ESR 14 mm/h
Sodium 145 mrnol/L
Potassium 4.4 mmol/L
Bicarbonate 1 8 mmol/L
Chloride 117 mmol/L
Urea 5.4 mmol/L
Creatinine 55 pmol/L
Calcium 3.02 mmol/L
Phosphate 0.7 mmol/L
ALP 1 00 U/L
Total protein 80 g/L
Globulins 39 g/L
Serum ACE 34 U/L
IgC 9.3 g/L
IgA 2.1 g/l
IgM 1.2 g/L
Electrophoresis Normal
Plasma PTH 4.2 pmol/L
24-hour urine:
Volume 3900 ml.
Creatinine 2.64 pmol/L
Calcium 2.35 mmol/L

26
 ENDOCRINOI OCY AND METABOLISM - QUESTIONS

1 What is the diagnosis?

ÿ A Raised anion gap metabolic acidosis
ÿ B Secondary hyperparathyroidism
D C Multiple endocrine neoplasia (MEN) type 2A
ÿ D Familial hypercalcaemic. hypocalciuria
( ) E Primary hyperparathyroidism

27
ENDOCRINOLOGY AND METABOLISM - QUESTIONS
Case 5

You are called to see a 68-year-old retired nurse who collapsed while
having a lipoma removed from his back under a general anaesthetic. In the
past he had Osgood Schlatter's disease. He is on no medication. His
mother has type I diabetes, his two sisters are well.
On examination he is 1.88 m, weighs 80 kg, the pulse is 70 bpm, |VP 4 cm
and blood pressure 1 10/70 mmHg with no postural drop. His capillary
glucose was 1 .8 mmol/L during the collapse but he came round within
10 minutes after having 25 g intravenous glucose.

The patient is shown in the following figure:

Urinalysis Ketones ++

Prudently, some bloods were taken before the glucose was given. They are
as follows:
FBC Normal
Glucose 1.9 mmol/L
Sodium 135 mmol/L
Potassium 4.9 mmol/L
Bicarbonate 20 mmol/L
Chloride 104 mmol/L
Urea 3.5 mmol/L
Creatinine 70 pmol/L
LFTs Normal
Cortisol 315 nmol/L

28
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

1 What is the next best step?

ÿ Fast for up to 72 hours and measure insulin, C-peptide and
A
P-hydroxybutyrate- if hypoglycaemia occurs
D B Perform basal anterior pituitary function tests
CD C Urine or plasma sulphonylurea screen
ÿ D Short tetracosactrin test (250 ug Synacthen® intramuscularly, serum
Cortisol at 0, 30, 60 minutes)
I E Measure plasma ACTH

29
ENDOC RINOLOGY AND METABOLISM - QUESTIONS

Case 6

You see a 36-year-old lady III hours after her admission after palpitations
which self-terminated. She is a gardener for the Royal Horticultural
Society, smokes one or two cigarettes a week anddrinks one bottle of wine
every 2 days. She has no past medical history. She suffers with aches and
pains all over which predate this presentation.
On examination the muscles are not tender and apart from being
proximally weak - she cannot rise from a squat - the neurological
examination, including the deep tendon reflexes, is normal; examination
of the respiratory and abdominal systems are normal. The J VP is 4 cm and
shows couplets of cannon waves and the BP is 1 40/94 mmHg.
Urinalysis pH 6.1
Protein trace
Blood trace
Specific gravity 1 .010
The ECG shows U waves, but is otherwise entirely normal.
Her investigations are shown:
EBC Normal
ESR 5 mni/h
CRP <1 mg/L
Sodium 1 44 mmol/L
Potassium 2.2 mmol/L
Bicarbonate 6 mmol/L
Chloride 1 25 mmol/L
Urea 7.8 mmol/L
Creatinine 100 umol/L
Calcium 2.2 mmol/L
Phosphate 0.7 mmol/L
Albumin 40 g/L
ALP 129 U/L
AST 22 U/L
ALT 15 U/L
Bilirubin 9 umol/L

The ward house officer was concerned about some abdominal pain and
requested the abdominal film shown opposite:

30
 ENDOCRINOLOGY AND METABOLISM - QUE ST IONS

Science Photo Library

1 What is the diagnosis?

ÿ A Cushing's syndrome
ÿ B Distal renal tubular acidosis (type 1)
ÿ C Proximal renal tubular acidosis (type 2)
ÿ D Distal renal tubular acidosis (type 4)
ÿ E Primary aldosteronism (Conn's syndrome)

31
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 7

A 29-year-old lady Is admitted with a thunderclap frontal headache with

severe pain behindthe eyes. On direct questioning she had hadsome mild
headaches for the preceding few days but hadput that down to becoming
increasingly exhaustedover the previous months because of her work. She
haddouble vision on looking to the left when the headache first came on.
Recently she has lost 4 kg in weight. She takes no medications except the
combinedcontraceptive pill.
On examination the temperature is 37.9 °C, pulse 1 10 bpm, BP 90/60
mml Ig. She became too unsteady to get a standing BP. On examination of
the external ocular movements she has a left Vlth nerve palsy, but there are
no other localising signs in the neurological examination. The discs are
normal. Examination shows the breasts are normal and there is nothing to
suggest a gynaecological malignancy.
She has a CT scan which does not show any blood and after 12 hours has a
lumbar puncture:
Opening pressure 13 cmH.O
CSF appearance Clear and colourless
CSF microscopy:
Lymphocytes < 4/mnr
Polymorphs 0
Red cells 0
CSF glucose 3.0 mmol/L
CSF protein 500 mg/L
Serum investigations are performed:
Sodium 120 mmol/L
Potassium 3.4 mmol/L
Urea 4 mmol/L
Creatinine 80 pmol/L
Serum osmolality 253 mosmol/kg
Urine osmolality 360 mosmol/kg

1 Which investigation will be most helpful?

0 CT brain with contrast
A
0 Cortisol and ACTI I
B
ÿ C MRI pituitary
ÿ D Urinary sodium
ÿ E CT orbit
0 F Send CSF to virology for examination before commencing aciclovir

32
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS
Case 8

/\ 14-year-oldboy is beinginvestigated for the possibility of diabetes. He is

fairly well and has not lost any weight. He hadbeen treated for
seborrhoeic eczema in the past without much success - the rash is still
present. As a child, while in another country, he hadbeen investigated for
a soft-tissue masson his head; the mass is stillpresent. His mother has kept
his X-rays from when he was a younger childand the skull X-ray is shown.
Urinalysis Ketones +
Specific gravity 1.002
His morning chemistry is shown:
Sodium 144 mmol/L Plasma glucose 5.0 mmol/L
Potassium 4.0 mmol/L Albumin 40 g/L
Chloride 1 08 mmol/L ALP 300 U/L
Bicarbonate 26 mmol/L ALT 30 U/L
Urea 3.0 mmol/L Bilirubin 9 umol/L
Creatinine 80 umol/L

1 What is the underlying diagnosis?

ÿ A Primary hyperparathyroidism
ÿ B Multiple myeloma
ÿ C Langerhans' cell histiocytosis
ÿ D Neurofibromatosis type 1
CD E Metastatic carcinoma

33
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 9

A 39-year-old lady attended for removal of a breast lump. Surgery was

postponed because her BP was 200/1 10 mmHg, with no postural drop.
She is on no medication and eats a normaldiet. The /VP was 4 cm.
Urinalysis:
pH 7
Ketones Negative
Protein Trace
Blood Non-haemolysed trace
Your investigations reveal:
Sodium 140 mmol/L
Potassium 3.7 mmol/L
Bicarbonate 34 mmol/L
Chloride 96 mmol/L
Urea 6 mmol/L
Creatinine I 10 pmol/L
Plasma renin activity < 0.5 pmol/mL/h
Aldosterone 925 pmol/L
Urine:
Noradrenaline 500 nmo1/24 h (NR < 570 nmol/24 h)
Adrenaline 90 nmol/24 h (NR < 144 nmol/24 h)
Dopamine 2000 nmol/24 h (3100 nmol/24 h)
Aldosterone 1 00 nmol/24 li
Ratio of cortisol/cortisone
metabolites Normal
Deoxycorticosterone (DOC) Normal
(S-HCG Negative
Renal ultrasound Normal
The adrenal CT is shown opposite.

1 What is the diagnosis?

ÿ A Primary aldosteronism - bilateral adrenal hyperplasia
ÿ B Liddlc's syndrome
ÿ C Essential hypertension
ÿ D Bartter's syndrome
0 E Primary aldosteronism - unilateral adenoma
0 E Phaeochromocytoma

34
ENDOCRINOLOGY AND METABOLISM - QUESTIONS
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 10

A 49-year-old man with type Idiabetes who is awaiting panretinal

photocoagulation for proliferative retinopathy has central crushing chest
pain with associated nausea and breathlessness. He has diabetic
nephropathy, is on twice-daily Novomix-30®, with a recent HbAu of
1 1.6% and had recently been advised to discontinue driving because of
loss of hypoglycaemia awareness. His other medication is aspirin 75 mg
once daily and 20 mg of simvastatin at night.
On examination he has a regular pulse of 88 bpm, the venous pressure is
4 cm, BP 95/68 mmHg, a third heart sound is present at the apex and the
chest is clear. His ECG shows anterior ST elevation, suggestive of
myocardial infarction. Primary angioplasty is unavailable.
The capillary glucose is 1 2.0 mmol/L
Urinalysis Protein++
Invesligations from the Diabetes Clinic the previous clay show:
Sodium 135 mmol/L
Potassium 5.0 mmol/L
Bicarbonate 19 mmol/L
Urea 10.1 mmol/L
Creatinine 230 umol/L
Glucose 12.6 mmol/L
Cholesterol 3.9 mmol/L
Bilirubin 10 pmol/L
Albumin 40 g/L
AST 1 05 U/L
ALT 100 U/L

1 Which of the following statements is incorrect?

ÿ A Thrombolysis should be administered
ÿ B p-Blockade should be given post-infarct
ÿ C ACE inhibition should be given post-infarct
ÿ D Intravenous p-blockade should not be given alongside thrombolysis
ÿ E The statin should be discontinued

36
 FNDOCRINOLOCY AND METABOLISM QUESTIONS

Case 11

A 39-year-old researcher at the European Parliament has abdominaland

back pain which has come andgone for the last 18 months and is
worsening. He smokes 20 cigarettes a clay. He had always enjoyed wine
while studying politics at university. However, because of the recurrent
abdominal pain, he has not drunk for the last year. He has lost a little
weight. He is not married.
On examination he weighs 68 kg and is 1.88 m tall. There is no spinal
tenderness. The capillary glucose is 7.9 mmol/L-
Urinalysis pH 6
Specific gravity 1.020
Investigations reveal:
Hb 12.1 g/dL
WCC 5.0 x 10'VL
MCV 97 fL
Platelets 150 x 107L
Bilirubin 42 pmol/L
Albumin 36g/L
ALP 200 U/L
ALT 20 U/L
Amylase 100 U/L
Vitamin D 35 nmol/L (NR 45-90 nmol/L)
Cortisol 200 nmol/L
I lis spinal X-ray is shown overleaf.

37
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

1 What is the diagnosis?

ÿ A Bone metastases
ÿ B Osteomalacia
ÿ C Chronic pancreatitis
ÿ D Carcinoma of the head of the pancreas
ÿ E Tuberculous adrenalitis

38
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 12

You see a 22-year-old man for a second opinion regarding his

endocrinology investigations for lassitude, weakness and cramps after
exercise. Ilis serum Cortisol hadbeen measured at 170 nmol/L.
He was always tired as a childandperformedpoorly at sports
in part, his parents used to say to his annoyance, because he was
always a frail, sickly child. He suffers with such severe cramp when
climbing even a few stairs that he now always takes the lift. He does not
smoke or drink.
On examination he is thin, 1 .8 m tall and weighs 57 kg. The skin is normal,
there is no goitre or lymphadenopathy. He has a pulse of 88 bpm and BP of
130/70 mml Ig with no drop, and a normal respiratory and abdominal
examination. I lis thighs are wasted, there is no fasciculation, he cannot
rise from a squat, the reflexes and sensation are normal.
Urinalysis Ketones +
Protein negative
Blood ++
Specific gravity 1 .02 1
Glucose negative
Bilirubin negative
fasting 9-am investigations after exertion show:
Cortisol 600 nmol/l
ACTH 15 pmol/L (NR at 9 am < 1 8 pmol/L)
FBC Normal
ESR < I mm/h
Creatine kinase 300 U/L
Glucose 5.0 mmol/L
Bicarbonate 24 mmol/L
Urea 2.2 mmol/L
Creatinine 50 pmol/L
LDH 320 U/L
LFTs Normal
Bone profile Normal
Corrected Ca2* 2.4 mmol/L
Urine microscopy No red cells or casts seen
Sparse granular and hyaline casts

}9
ENDOCRINOLOGY AND MFTABOI ISM - QUESTION'S

1 What is the diagnosis?

0 ACushing's disease
0 BPompe's disease
O C Cyclical Cushing's syndrome
O D McArdle's disease
i J E Addison's disease

40
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 13
A 55-year-old man who is asymptomatic has on two separate occasions
shown the following venous plasma biochemistry:
Random glucose 6.1 mmol/L
75-g glucose tolerance test:
T+0 6.0 mmol/L
T + 120 1 1 .0 mmol/L

1 What is the diagnosis?

Diabetes mellitus
A
ÿ Impaired fasting glucose
B
0 C Impaired glucose tolerance
0 D Normal
0 E Impaired fasting glucose and impaired glucose tolerance

41
ENDOCRINOLOGY AND MFTABOI ISM - QUESTIONS

Case 14

You arc asked to see a 70-year-old lady on the Orthopaedic Ward who
fractured her hip. She is 24 hours post-op from a dynamic hip screw
insertion under general anaesthesia and is mildly nauseatedbut able to
keep water down. She has COPD, well controlledon inhalers, andtakes
aspirin anda nitrate for mildstable angina - which has not troubledher for
'years'.
On examination she is orientated, pale, apyrexial, pulse 96 bpm, BP 90/50
mmHg lying and 96 bpm and 90/50 mmHg standing, and the JVP is 3 cm.
Her chest is clear.

Urinalysis Blood negative

Protein negative
Ketones +
pH 5.4
Her morning investigations are as follows:

Hb 9.9 g/dL
MCV 90 fL
Platelets 604 x 107L
Sodium 124 mmol/L
Potassium 5.1 mmol/L
Bicarbonate 22 mmol/L
Chloride 100 mmol/L
Urea 3.1 mmol/L
Creatinine 50 [tmol/L
Calcium 2.4 mmol/l
Phosphate 1.1 mmol/L
Albumin 40 g/1
t4 15.1 pmol/L
TSH 2.1 U/L
Cortisol 120 nmol/L
Glucose 4.3 mmol/L
Urine osmolality 180 mosmol/kg
Plasma osmolality 271 mosmol/kg

1 Which of these is the best treatment?

ÿ Restrict fluids lo 500 mL/day
A
ÿ B Intravenous 0.9% saline 80-125 mL/h
CD C Hydrocortisone 100 mg intramuscularly 6-hourly and fludrocortisone
50-100 ug orally bd
0 D Hydrocortisone 100 mg intravenously stat and 20 mg orally tds
ÿ E DDAVP 1 pg intramuscularly stat

42
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 15

A 32-year-oldman hada rather sudden onset of sore throat, dysphagia and

pain in the right ear 2 weeks previously. He is anxious, tremulous and
sweaty.
On examination he has a fine tremor, the palms are moist and warm, the
temperature is 38 °C, pulse 112 bpm and collapsing, BP 120/70 mmHg,
and |VP 4 cm. In the neck there is a tender, slightly irregular, firm goitre
with the right lobe being the larger; the overlying skin is faintly
erythematous.
This is the appearance of his eyes:

Investigations reveal:
Hb 12.0 g/dL
WCC 12.0 x 109/L
Platelets 397 x 107L
ESR 68 mm/h

1 What is the likely diagnosis?

CD A Haemorrhage into a cyst
ÿ B Iodine-induced thyrotoxicosis (Jod-Basedow phenomenon)
CD C Subacute thyroiditis
ÿ D Graves' disease
ÿ E Riedel's thyroiditis

2 What is the diagnostic investigation?

ÿ A ,
Free T4, free T and TSH
CD B Thyroglobulin
CD C Ultrasound and fine-needle aspiration (FNA)
ID D Radioactive iodine uptake scan
ID E Thyroid autoantibodies
43
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 16

You are asked to see a 44-year-old Irish lady who is under investigation foi
colicky abdominal pain, nausea and vomiting, and lassitude which all
come andgo somewhat. She is a university lecturer who has been unwel
with these symptoms over the last 9 monthsbut has continuedto work; she
has lost 10 kg.
On examination she is 1.70 m tall and 57 kg and looks unwell. The pulse is
90 bpm, BP 120/80 mmHg lying and 90/52 mmHg standing, |VP 2 cm.
Examination of the breasts, respiratory, abdominal and neurological
systems is normal.

Her CXR is normal.

Morning investigations are performed:

Sodium 130mmol/L
Potassium 6.3 mmol/L
Urea 10 mmol/L
Creatinine 110 ,umol/L
Cortisol 210nmol/L
ACTH 1 90 pmol/L (NR at 9 am < 1 8 pmol/L)
T-i 15.1 pmol/L
TSH 3.1 mU/L

44
 ENDOCRINOLOGY AND MFTABOI ISM QUESTIONS

1 Which lest should be performed next?

C A Short tetracosactrin (Synacthen®) test 250 pg tetracosactrin
intramuscularly at time 0
HI B Long tetracosactrin lesl - I mg tetracosactrin deep intramuscular
injection at time 0
I. I C Very-long-chain fatty acids
( ) D Adrenal cortex and 21 -hydroxylase autoantibodies
ÿ E Insulin tolerance test 0.15 U/kg insulin at lime 0

45
ENDOCRINOLOGY AND METABOl ISM - QUESTIONS

Case 17

A 32-year-old lady is seen in the Diabetes Clinic for 6-monthly review. She
has had type Idiabetes mellitus ( T 1DM) for the last 15 years. She is treated
with insulin aspart 8-12 units pre-meal and human Insulatard® 18 units at
10 pm. She monitors frequently and while some days can be good with
fasting capillaryglucose in the range of 4.5-6.5 mmol/L andpost-prandial
levels of no higher than 9.5 mmol/L,she can wake with lasting sugars
around 12-15 mmol/L andthen the whole day is erratic. She always has a
bedtime snack andshe suspects she is having nocturnal hypoglycaemia.
The HbAic is 7.2% andshe has no demonstrable complications. She is
having no meter or pen problems.
On examination her weight is stable at 70 kg and she has a BMI of
22 kg/rrr; the injection sites are fine.
Investigations reveal:
Tissue transglutamase antibodies Negative
9-am Cortisol 400 nmol/L
p-l ICG < 5 U/L

1 What do you recommend?

ÿ A Decrease the dose of the evening pre-meal aspart
CD B Decrease the dose of the nocturnal Insulatard""
CD C Add metformin
ÿ D Change the nocturnal Insulatard® to insulin glargine
ÿ E Perform a short tetracosactrin test

46
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 18

A gentleman has been investigated for hip/thigh pain. This is his pelvic
X-ray:

1 What is the likely diagnosis?

ÿ A Hyperparathyroidism
ÿ B Osteomalacia
ÿ C Acromegaly
D D Metastatic prostate carcinoma
ÿ E Paget's disease

47
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 19

This gentleman's foot is warm, swollen and red, but is not painful.
On examination the skin is intact - there is no ulceration. The foot is not
tender. Peripheral pulses are present.

Investigations reveal:
Plasma glucose 15 mmol/L
Urate 400 mmol/L

1 What is the likely diagnosis?

ÿ A Acromegaly
ÿ B Gout
ÿ C Charcot's foot
D D Osteomyelitis
ÿ E Cushing's syndrome

48
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

2 What is the appropriate next step?

ÿ Intravenous amoxicillin and flucloxacillin
A
D Colchicine ± subsequent allopurinol
B
D C Growth hormone day-curve and check insulin-like growth factor-l
(IGF-I) levels
_ D Low-dose (0.5 mg 6-hourly for 48 hours) dexamethasone suppression
test
ÿ E Immobilisation and forbid weight-bearing

49
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 20

This 45-year-old lady is seen in the Diabetes Clinic. She is currently only
taking metformin Ig bd, rosiglitazone 4 mg once daily and amlodipine
10 mg once daily. She does not smoke.
On examination her BMI is 32 kg/m2 and she has a blood pressure of
150/90 mmHg. Examination of the praecordium, respiratory and
abdominal systems is normal.

50
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Urinalysis Glucose negative

Blood ++ (menstruating)
Fasting investigations:
HbA,c 8.0%
Plasma glucose 5.9 mmol/L
Cholesterol 4.1 mmol/L
LDL cholesterol 3.0 mmol/L
HDL cholesterol 0.7 mmol/L
Triglycerides 2.1 mmol/L
Bilirubin 12pmol/L
Albumin 37 g/L
ALT 60 U/L
AST 50 U/L
ALP 121 U/L
yGT 50 U/L
Prothrombin time 15.1 s
HBsAg Negative
Hepatitis C virus Ab Negative
Ultrasound of the liver shows no biliary dilatation.

1 What is the likely diagnosis?

ÿ A Cush ing'ssyndrome
ÿ B Normal glucose tolerance
ÿ C Adrenal carcinoma
ÿ D Haemochromatosis
ÿ E Rosiglitazone-induced hepatitis

2 Which two are the appropriate next steps?

ÿ A Stop the rosiglitazone
ÿ B Increase the rosiglitazone
ÿ C Stop the metformin and the rosiglitazone
ÿ D Endoscopic retrograde cholangiopancreatography (ERCP)
ÿ E MRI pituitary
ÿ F Serum ferritin
ÿ G Midnight serum Cortisol
ÿ H Prescribe a statin
ÿ 1 Liver biopsy
ÿ ) 48-hour low-dose dexamethasone suppression test

51
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 21

This 50-year-oldgentleman has macular degeneration, the opthalmologist

asks you to see him as his bloodpressure is 150/100 mmHg. This is his
right hand:

1 Which two diagnostic tests will you perform on him?

ÿ A Growth hormone day-curve
ÿ B X-ray hands
ZD C Anti-nuclear and extractable nuclear antibodies
ÿ D Measure growth hormone during an oral glucose tolerance test
ÿ E Pituitary MRI
ÿ F Measure growth hormone during an insulin tolerance test
CD G Serum alkaline phosphatase
J H Serum urate
ÿ I Rheumatoid factor
ÿ ) Serum albumin

52
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 22

This 49-year-old lady complains of nocturia for the past 6 months:

1 What is the diagnosis?

D A Acromegaly
ÿ B Diabetic cheiroarthropathy
ÿ C Osteoarthritis
ÿ D Hyperparathyroidism
CD E Osteomalacia

53
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 23
A CP refers you a 65-year-old gentleman with breathlessness which has
been present and slowly worsening for the last few weeks. The CP is
concernedthat there is something he is missing. The patient is not wheezy
but has hada cough productive ofgreen sputum for the last 2 days that has
not responded to amoxicillin as well as normally; the CP had treated him
for several infections, including pneumonia twice and urinary tract
infections over the preceding months. He normally has a cough
productive of white sputum. He has lost 5 kg in weight over the last 3
months and on direct questioning says he lost his appetite, is not sleeping
and is feeling frankly miserable. There have been no night sweats. No
prescription medication is taken but he takes magnesium trisilicate several
times daily for a very troublesome hiatus hernia; he is married with two
grown-up children, recently retired as a bank clerk, drinks approximately
30 units of alcohol a week and keeps no pets.
On examination he is thin, pale and looks a little unwell. His respiratory
rate is 24 breaths per minute, the chest is clear and there is no wheeze. The
pulse is 96 bpm, BP 130/70 mmHg and the heart, abdomen and nervous
system are normal.

Urinalysis Protein negative

Sputum Thick, green, purulent
Spo, 94%

Investigations:
Hb 8.8 g/dL
MCV 84 fL
WCC 3.1 x I07L
Neutrophils 1.1 x I07L
Lymphocytes 2.0 x IO'VL
Platelets 120 x 10'VI
ESR 1 10 mm/h
Sodium 1 39 mmol/L
Potassium 4.9 mmol/L
Bicarbonate 19 mmol/L
Chloride 106 mmol/L
Urea 19.1 mmol/L
Creatinine 180 umol/L
Calcium 2.7 mmol/L
Phosphate 1 .8 mmol/L
Albumin 26 g/L
ALP 90 U/L
Total protein 78 g/L

54
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS

1 What is the diagnosis?

CD A Squamous cell carcinoma of the lung
CD B Multiple myeloma
CD C Bone metastases
CD D Hyperparathyroidism
ÿ E Milk alkali syndrome

55
ENDOCRINOLOGY AND METABOLISM QUESTIONS

Case 24

A local CP has asked you lo see a 29-year-old lady who complains ol

palpitations which have been present for the last 2 months. 5he has
diarrhoea.
The CP had her thyroid function tests assayed at a local district general
hospital 3 months ago which revealed:
FreeT, 30.1 pmol/L
Free T, 1 2.9 pmol/L
TSI I 4.3 mU/L
When you see her the pulse is 1 10 bpm and she has a small goitre.
Urine (3-HCG is negative.
On the assay at your hospital the investigations reveal:
Free T, 32.1 pmol/L
FreeT, 14.1 pmol/L
TSH 4.9 mU/L

1 What is the appropriate next step?

D A Serum (3-1 ICG
ÿ B Repeat the tests
ÿ C Pituitary MRI
CD D Thyrotrophin-releasing hormone (TRH) test
CD E Check serum Cortisol

56
 ENDOCRINOLOGY AND METABOLISM QUESTIONS

Case 25

A 52-year-oldjournalist , who has been followed up in the Diabetes Clinic

since diagnosis 3 years ago, is brought to A&E with a gastrointestinal
bleed. His diabetes is always fairly well controlled on metformin 850 mg
bdandpioglitazone 15 mg once daily with an HbAh of 6.9%. He does not
smoke but likes to have a couple of whiskeys while listening to the radio in
the evening. He is marriedwith three children who are well. His father had
diabetes mellitus and died ot heart failure at 49 years ofage. He is
otherwise well, apart from some arthritis in his knees, for which he takes
simple analgesia.
On examination he has pale conjunctivae, is tanned and has abdominal
obesity and swollen knees. I lis pulse is 120 bpm and chaotic, BP 1 10/90
mmHg with postural symptoms. There is 3-cm hepatomegaly. The chest is
normal and he has absent ankle jerks. You resuscitate him appropriately.
Investigations:
I lb 9.0 g/dL
WCC 10x10"/L
MCV 90 fL
Platelets 90 x 10"/L
Prothrombin time 19 s
Fibrinogen I.Bg/L
Albumin 32 g/L
AIT 90 U/L
AST 90 U/L
yGT 120 U/L
Bilirubin 23 pinol/l
Creatine kinase 140 U/L
He has an endoscopy in the morning, showing varices which are banded.

1 What is the diagnosis?

D A Simvastatin-induced hepatitis
D B I Hemochromatosis
CD C Rosiglitazone-induced liver failure
CD D Alcoholic cirrhosis
CD E NSAID-induced peptic ulceration

57
ENDOCRINOLOGY AND METABOLISM - QUESTIONS
Case 26

A patient presents showing the following changes on X-ray:

Wellcome Trust Medical Photographic Library

1 What biochemical abnormalities would you expect in this patient?

ÿ A Elevated renin, normal anion gap acidosis, hyperkalemia, high TSH
O B Hypercalcaemia, normal anion gap acidosis, hypophosphataemia
ÿ C Elevated renin, high aldosterone, hypokalaemia, alkalosis
ÿ D Low potassium, low chloride, hypophosphataemia, elevated alkaline
phosphatase
ÿ E Etypokalaemia, elevated plasma catecholamines, hyperglycaemia

58
 ENDOCRINOLOGY AND METABOLISM QUESTIONS

Case 27

You suspect that a 55-year-oldlady with hypertension, dyslipidaemia,

diabetes mellitus and osteoporosis has Cushing's syndrome based on
suspicious appearance; you perform some investigations:
9-am Cortisol 590 nmol/L
Cortisol after 48 hours of dexamethasone 0.5 mg 6-hourly 290 nmol/L
Cortisol after 48 hours of dexamethasone 2 mg 6-hourly 140 nmol/L
Plasma ACTH awaited

1 What is the likely diagnosis?

ÿ A Ectopic ACTH secretion
/ I? Adrenal carcinoma
*
! C Cushing's disease
'
I D Adrenal adenoma
IJ E Normal

59
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 28

A 24-year-old patient is seen in the clinic with type Idiabetes of 1 1 years'

duration. His glycaemia is acceptable on insulin dctemir 10 units bdand
insulin aspart 8, 10, 8 pre-meal - the HbA,c is 7.4%. He has background
retinopathy which is under follow-up and mildasymptomatic peripheral
sensory neuropathy. He had an albumin/creatinine ratio (ACR) of
2. 9 mg/mmol 6 weeks ago at his surgery. He does not smoke.
On examination his weight is 69.1 kg and BMI 20 kg/mC Blood pressure is
1 28/78 mm! tg. He has microaneurysms, blot haemorrhages and four hard
exudates in the periphery; the acuity is 6/6 bilaterally.
Urinalysis Protein negative
Blood negative
Investigations:
first morning urine albumin/creatinine ratio 2.7 mg/mmol
Total cholesterol 3.6 mmol/L
IIDE cholesterol 1 .3 mmol/L
LDL cholesterol 2.2 mmol/L
Triglycerides 1 .8 mmol/L
Creatinine 80 (imol/L

1 What should you do?

ÿ Start aspirin, a standard dose of statin and start an ACE inhibitor and
A
titrate to the maximum dose
ÿ B Start an ACE inhibitor and titrate to the maximum dose
0 C Start aspirin and an ACE and titrate to the maximum dose
0 D Start aspirin alone
0 E Start an ACE inhibitor, titrate to the maximum dose and refer to an
ophthalmologist for laser photocoagulation

60
 ENDOCRINOI OGY AND METABOLISM QUESTIONS

Case 29

A 69-year-oldAsian gentleman is seen in Outpatients after a recent stent to

his left anterior descending artery. He is pain-free. He takes atenolol
100 mg once daily, amlodipine 10 mg once daily, ramipril 10 mg once
daily, aspirin 75 mg once daily, clopidogrel 75 mg once daily, metformin
850 mg Ids, pioglitazone 15 mg and atorvastatin 80 mg at night. He had
pancreatitis caused by hypertriglyceridaemia 3 years ago when his
diabetes mellitus was diagnosed; he was taking colestyramineat that time.
He is an ex-smoker and takes no alcohol.
On examination, BP is 120/70 mml Ig and BMI 28 kg/m2.
You are asking the dietician to see him again.
These are his lipids:
Total cholesterol 5.4 mmol/L
LDL cholesterol 3.2 mmol/L
HDL cholesterol 1.2 mmol/L
Triglycerides 1.9 mmol/L
Creatine kinase 1 00 U/L
ALT 25 U/L
AST 20 U/L
HbAu 6.9%

1 Which of the following is the most prudent?

ÿ A Add a fish oil
O B Add a fibrate
ÿ C Re-challenge with colestyramine
ÿ D Add nicotinic acid
ÿ E Add ezetimibe

61
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 30

A 72-year-oldgentleman is admitted lo hospital alter collapsing in the

street,outside his house. The initial diagnosis is a stroke as he has a dense
right hemiparcsis. His conscious level is decreased anddetails are initially
scarce. Ilis fingers are tar-stained. Your computer system tells you he is
seen in the Movement Disorder Clinic and was admitted .5 months ago for
5 days under the geriatricians.
On examination he is responsive only to pain, and tolerating a Cuedel's
airway. He has generalised obesity and is pale. His is cool round the
peripheries, the pulse is 60 bpm and chaotic, BP 1 20/90 mmHg, the apex
is impalpable but the heart sounds are normal, the respiratory rate is 1 6
breaths per minute, there are coarse crackles posteriorly at the bases to the
mid-zones with bronchial breathing, the abdomen is distended but there is
no organomegaly. The ankle jerks are absent. Sp02 is 94%. Capillary
glucose is 4.1 mmol/L.
Initial investigations reveal:
lib 13.1 g/clL
MCV 98 fL
wee 10.1 x 1071.
Platelets 200 x 10'VL
Sodium 122 mmol/L
Potassium 3.5 mmol/L
Urea 12.1 mmol/L
Creatinine 124 mmol/L
Serum osmolality 267 mosmol/kg
His chest X-rays are shown opposite.

62
 ENDOCRINOLOGY AND METABOLISM - QUESTIONS
Chest X-ray, 5 months ago

Chest X-ray, now

1 What is responsible for this appearance?

_ A Aspiration pneumonia
_ B Amiodarone
ÿ C Lithium
Q D Cabergoline
C E Demeclocycline

63
ENDOCRINOLOGY AND METABOLISM - QUESTIONS

Case 31

A 62-year-old man is admitted after a collapse. He has a 'turn' on the ward

andhis capillary glucose is found to be 2.2 mmol/L. With 50 mL of 50%
dextrose he recovers rapidly andthe capillary glucose rises to 7 mmol/L.
Hegoes on to have a 72-hour fast.
Urinalysis No abnormalities detected
These are the data after 18 hours of fasting, when he becomes unwell:
Glucose 2.1 mmol/L
Insulin 40 pmol/L
C peptide 500 pmol/L
Cortisol 580 nmol/L
Plasma sulphylureas Absent
Growth hormone 44 mU/L (NR basal, fasting and between
pulses < 1 mU/L, after hypoglycaemia
> 40 mU/L)
Prolactin 300 mU/L (NR < 360 mU/L)
Calcium 2.4 mmol/L
Albumin 40 g/L

1 What is the correct cause?

CD A Exogenous insulin administration
f j B Non-islet-cell hypoglycaemia
I j C Insulinoma
ÿ D Multiple endocrine neoplasia type 1 (MEN 1)
ÿ E Sulphonylurea or nate/repa-glinide administration

64
 GASTROENTEROLOGY - QUESTIONS

Case 1

A 55-year-old man diagnosed with total ulcerative colitis at the age of 20

presented with a 3-month history of rectal bleeding. He was opening his
bowels twice a day, passing formed stool. His colitis hadbeen
well-controlled for the last 10 years with oral mesalazine 400 mg bd.
His blood tests were as follows:
Hb 8.6 g/dL
MCV 75 fL
VVCC 4.8 x 10''/L
Platelets 387x107L
CRP 5 mg/L

1 What is the most appropriate next step?

D A Oral prednisolone 40 mg/day
CD B Increase oral mesalazine to 800 mg tds
CD C Colectomy
CD D Colonoscopy
CD E Azathioprine 2 mg/kg/day

67
GASTROENTEROLOGY - QUESTIONS

Case 2

Four weeks after returning from a trip to the Indian subcontinent, a

44-year-old woman presented to A&F complaining that she hadbeen
feeling unwell for about a week with symptoms of nausea and anorexia.
She did not drink alcohol, look no regular medications andhadhad only
one sexual partner for the last few years. There was no past medical history
of note.
Examination revealed a tender liver, palpable to 4 cm below the costal
margin. The spleen was also just palpable. Blood results were as follows:
Sodium 1 39 mmol/L
Potassium 3.7 mmol/L
Urea 2.8 mmol/L
Creatinine 76 pmol/L
Albumin 35 g/L
Bilirubin 2 1 umol/l
AST .345 U/L
ALT 7.55 U/L
ALP 2.56 U/L
Hepatitis A IgG positive
Hepatitis A IgM negative

1 Which of the following is the most likely diagnosis?

ÿ A Acute hepatitis A
ÿ B Acute hepatitis C
CD C Chronic hepatitis A
ÿ D Acute hepatitis B
CD E Acute hepatitis E

68
 GASTROENTEROLOGY - QUESTIONS

Case 3

A 24-year-old lady with an 8-year history of ileocolonic Crohn's disease

presented with a 2-day history of shortness ot breath. She hadsmoked 10
cigarettes a day for the last 10 years. Her Crohn's disease hadbeen difficult
to-control and she had recently been started on oral prednisolone, 40 mg
per day, in addition to her usual medications of oral mesalazineand
methotrexate, both of which she hadbeen taking for many years.
On examination she had a respiratory rate of 22 breaths/minute and her
pulse was 1 10 bprn. Auscultation of her chest was unremarkable.

1 Which of the following tests is the most appropriate?

ÿ A Plain chest X-ray
CD B Ventilation-perfusion scan
L.J C Pulmonary function tests
ÿ D D-dimer levels
CD E Lung biopsy

69
GASTROENTEROLOGY - QUESTIONS

Case 4

A 31-year-old lady presents with a 2-month history of malaise and

anorexia. She drinks 2 1 units of alcohol a week and returned from a
holiday in South-East Asia 3 months previously. She is on no regular
medication and has not had any recent sexual contacts.

Her investigations were as follows:

Hb 11.6 g/dL
MCV 87 fL
WCC 4.8 x 107L
Platelets 115 x 107L
Bilirubin 30 pmol/L
ALT 345 U/L
Albumin 36g/L
ALP 124 U/L
Total protein 90 g/l.

1 What is the most likely diagnosis?

O A Autoimmune hepatitis
LJB Hepatitis A virus infection
0 C Alcoholic liver disease
ÿ D Gallstones
0 E Primary biliary cirrhosis

70
 GASTROENTEROLOGY - QUESTIONS

Case 5
A 64-year-old lady presented with a 2-day history of melaena and
epigastric pain. She had a history of osteoarthritis for which she took
diclofenac.
On admission she had a pulse of 125 bpm. Her blood pressure was 1 10/70
mmHg lying and 1 00/50 mmHg when sitting. She was resuscitated with
intravenouscolloid. At endoscopy, she was found to have a stricture in the
mid-oesophagus which prevented passage of the endoscope. She
continued to have melaena and accordingly had angiography performed
which is shown below.

1 What is the most likely source of her bleeding?

D A Oesophageal carcinoma
ÿ B Aortoenteric fistula
ÿ C Oesophageal varices
ÿ D Duodenal ulcer
ÿ E Meckel's diverticulum

71
GASTROENTEROLOGY - QUESTIONS

Case 6

A 42-year-old man is referred to Outpatients with a history of tiredness. He

hadpreviously hada prophylactic colectomy with ileostomy formation for
a family history of colorectal carcinoma.
The specimen from this operation is shown below. His ileostomy is
functioning normally and external examination is unremarkable.

His blood tests are as follows:

Hb 8.6 g/dl
MCV 72 fL
WCC 4.8 x 107L
Platelets 411x10,/L

1 What is the most likely diagnosis?

D A Vitamin B|2 malabsorption secondary to his resection
ÿ B Malabsorption of iron secondary to his resection
ÿ C Duodenal carcinoma
ÿ D Abdominal desmoids
ÿ E Pernicious anaemia

72
 GASTROENTFROLOGY QULSTIONS

Case 7
A 28-year-old woman of Irish descent was referred to hospital with a
history of malaise and tiredness for 6 months. She complained that her
bowels had always been erratic but were more so recently; she hadbeen
passingsemi-formed stools three times a day for the last few months. There
was no history of foreign travel and, other than the oral contraceptive pill,
she was on no regular medications.
Examination revealed that she was pale and undernourished. Her
laboratory investigations were as follows:
Hb 9.6 g/dL
MCV 74 fL
WCC 6.2 x 109/L
Platelets 22! x 107L
Sodium I 39 mmol/L
Potassium 3.7 mmol/L
Urea 2.8 mmol/L
Creatinine 76 umol/L
Albumin 33 g/L
Calcium 1 .76 mmol/L
Bilirubin 5 umol/l.
AST 23 U/L
ALP 94 U/L

Anti-endomysial Ab negative

1 What is the most appropriate test?

O A Capsule endoscopy
D B Barium follow through
ÿ C Duodenal aspiration for parasites
D D Serum IgA levels
D E Distal duodenal biopsy

73
GASTROENTEROLOGY - QUESTIONS

Case 8

A 74-year-old woman presented with a 4-month history of anorexia and

weight loss. She hadpreviously been fit and well and, apart from some
mild epigastric pain, had no other symptoms.
On examination she was clinically anaemic and had an area of abnormal
pigmentation on the back (see below).

1 What is the most likely diagnosis?

ÿ A Duodenal ulceration
B Coeliac disease
ÿ C Dietary folate deficiency
ÿ D Crohn's disease
ÿ E Gastric carcinoma

74
 GASTROENTEROLOGY - QUESTIONS

Case 9

A 35-year-old woman was referred to hospital with a 6-month history of

diarrhoea. She described the passageof watery stool up to five times a day
with associated cramping lower abdominal pain and bloating. There was
no history of foreign travel or of weight loss, andshe did not take any
regular medications.
Examination of the perianal region revealed some excoriation but digital
rectal examination and rigid sigmoidoscopy were normal. Her
investigations were as follows:
Hb 13.5 g/dL
MCV 90 f'L
WCC 5.8 x 107L
Platelets 387 x 107L
Sodium 138 mmol/L
Potassium 4.2 mmol/L
Urea 2.4 mmol/L
Creatinine 99 pmol/L
Albumin 44 g/l.
Corrected Ca~ ' 2.4 mmol/l
Bilirubin 1 4 urnol/L
CRP 5 mg/L

1 What is the most likely diagnosis?

r; A Coeliac disease
B Crohn's disease
.J C Small-bowel bacterial overgrowth
] D Infectious diarrhoea
ÿ E Bile-salt malabsorption

7.5
GASTROENTEROLOGY- QUESTIONS

Case 10

A 42-year-old lady presented to A&E with a 4-week history of fevers,

malaise, headacheanda cough productive of yellow sputum. She hadalso
notedoccasional fevers and had lost 3 kg in weight. She had a 20-year
history of small-bowel and perianal fistulating Crohn's disease for which
she was taking azathioprine (2 mg/kg) and had recently hadher second
infusion of anti-tumour necrosis factor-cc antibodies. Her diarrhoea and
abdominal pain had improved and the perianal fistulae hadbecome less
active. She smoked 20 cigarettes a day andhaddone so for 15 years.
On examination, her temperature was 37.4 °C and her chest had
occasional scattered wheezes throughout. Her abdomen was soft and
non-tender. Her chest X-ray is shown below.

1 What is the likely diagnosis?

D A Tuberculosis
D B Granulomatous lung disease
ÿ C Reaction to infliximab
D D Lung cancer
ÿ E Pneumonia

76
 GASTROENTEROLOGY - QUESTIONS

Case 11

A 55-year-old man was referred by his CP with recent onset of dysphagia.

Although able to swallow most of the time, he found that food stuck if he
did not chew it adequately. He had a long history of gastro-oesophageal
reflux for which he took a proton pump inhibitor, but he had never had an
upper gastrointestinal endoscopy. He was otherwise asymptomatic. He
had smoked 15 cigarettes a day for the last 40 years and drank two
measures of whisky each night before bed.
Examination of his abdomen was unremarkable and all his blood tests
were normal. A barium swallow was performed:

1 Which of the following is the most likely diagnosis?

ÿ A Diffuse oesophageal spasm
ÿ B Oesophageal carcinoma
ÿ C Achalasia
ÿ D Peptic stricturing
ÿ E Barrett's oesophagus

77
GASTROENTEROLOGY - QUESTIONS

Case 12

A 44-year-olcl man was referred by his CP with a 2-month history of

foul-smelling, greasy stools. He had recently returned from an 8- week trip
to Vietnam, his symptoms having developed about halfway through his
stay. His weight haddecreased by 4 kg over the last 4 weeks. Ile was
opening his bowels up to six times per day and had accompanying
abdominal pain, bloating and nausea. He drank 28 units of alcohol per
week and took multivitamins. External examination was unremarkable.
His CP had sent a stool sample for microscopy and culture, the results of
which were normal.

1 Which of (he following organisms is most likely to account for his

symptoms?
CD A Balantidium coli
I B Entamoeba histolytica
IJ C Ciardia lamblia
I D Cryptosporidium parvum
C E Entamoeba coli

78
 GASTROENTEROLOGY - QUESTIONS

Case 13

A 56-year-old Chinese woman presented to Outpatients with a history of

nausea, upper abdominal pain, abdominal swelling andweight loss. There
was no history of change in bowel habit or rectal bleeding andshe had no
past history of note.
Examination revealed jaundice, 4-cm, irregular hepatomegaly, and gross
ascites. No other masses were palpable in her abdomen.

Serum tumour markers were as follows:

u-fetoprotein 200 ng/ml
CEA 2 pg/L
CA 125 900 U/mL

A CT scan of her abdomen is shown below.

1 What is the most likely diagnosis?

O A Hydatid disease
0 B Hepatocellular carcinoma
ÿ C Metastatic ovarian cancer
0 D Metastatic colonic cancer
0 E Polycystic liver disease

79
GASTROENTEROLOGY - QUESTIONS

Case 14

A 33-year-old lady presented to A&E with a 2-week history of nausea and

vomiting, malaiseandheadache. She was 36 weeks pregnant and hadhad
three uncomplicatedpregnancies previously.

Examination revealed lhat she was normotensiveand had mild peripheral

oedema. Palpation of her abdomen revealed a gravid uterus consistent
with the duration of her pregnancy and mild tenderness in her right upper
quadrant. Her urine was negative for protein. Her blood tests were as
follows:
Hb 8.6 g/dL
MCV 98 fL
WCC 5.8 x 10"/L
Platelets 98 x 107L
Sodium 138 mmol/L
Potassium 4.4 mmol/L
Urea 4.4 mmol/L
Creatinine 99 umol/L
Albumin 32 e/l-
Bilirubin 30 pmol/L
AST 1245 U/L
AI.P 256 U/L

1 Which of the following is the most likely diagnosis?

[I A Acute fatty liver of pregnancy
I IB Hyperemesis gravidarum
ÿ C HELLP syndrome
D D Intrahepatic cholestasis of pregnancy
ÿ E Pre-eclampsia

80
 GASTROENTFROLOGY QUESTIONS

Case 15
A 52-year-oldgentleman was admitted with a history of haematemesis. He
haddrunk ten cans of strong lager a day for the last 10 years.
Examination revealed that he was lachycardic (1 1 0 bpm) and hypotensive
(95/60 mmHg supine). He was jaundiced and had multiple spider naevi on
hischest wall. His spleen was palpable on inspiration and shifting dullness
was detectable.
Blood results were as follows:
Hb 8.6 g/dl
MCV 104 f L
WCC 4.8 x 10'VL
Platelets 77 x IO'/L
PT 28 s
Sodium 129 mmol/L
Potassium 4.4 mmol/L
Urea 1 .4 mmol/L
Creatinine 78 umol/L
Albumin 23 g/L
Bilirubin 35 pmol/L
AST 245 U/L
ALP 256 U/L

1 Which of the following is not appropriate as pari of your immediate

management?
ÿ A Upper gastrointestinal endoscopy
D B Propranolol
CD C Intravenous Terlipressin
ÿ D Intravenous antibiotics
CD E Diagnostic peritoneal aspirate

81
GASTROENTEROLOGY - QUESTIONS

Case 16
A 19-year-old Bangladeshi man was referred to Outpatients with a history
of slight weight loss, crampy abdominal pain and, occasionally bloody
diarrhoea. He smoked 20 cigarettes a day, drank 14 units of alcohol per
week and worked as a mechanic. There was no past history of note. He
hadstarted taking ibuprofen for his abdominal pain and loperamide for his
diarrhoea.
On examination he was well, apyrexial and not tachycardic. He had mild
tenderness in his right iliac fossa but no masses were palpable in his
abdomen. His barium follow-through is shown below.

1 Which three of the following are most appropriate as part of your initial
management?
ÿ A Mesalazine ÿ F Infliximab
ÿ B Stop smoking ÿ G Vitamin B|_. injections
ÿ C Stop ibuprofen ÿ H Methotrexate
ÿ D Increase loperamide dosage ÿ I Parenteral hydrocortisone
ÿ E Azathioprine ÿ I Surgery

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 GASTROENTEROLOGY - QUESTIONS

Case 17

A 22-year-old student, who had recently returned from a holiday in South-

East Asia, presents to A&E complaining of worsening abdominal pain
following a 7-day history of bloody diarrhoea.
Examination revealed that he was pyrexial at 37.8 °C, sweaty and
tachycardic at 105 bpm. His blood pressure was 95/55 mmHg and
palpation of his abdomen revealed that he was diffusely tender. His plain
abdominal X-ray is shown below.

1 What should his subsequent management be?

ÿ Referral to the surgical team for laparotomy
A
ÿ Fluid resuscitation and antibiotics
B
ÿ C Fluid resuscitation and await stool cultures
ÿ D Sigmoidoscopy for deflation of the large bowel
ÿ E Fluid resuscitation, nil by mouth and nasogastric aspiration

83
GASTROENTEROLOGY - QUESTIONS

Case 18

A 19-year-old woman was brought into hospital by her mother who had
recently returnedhome to find that her daughter was unwell. Two days
previously,the daughter had split up from her boyfriend andhadtaken
about 50 paracetamol tablets after drinking a quarter of a bottle of spirits.
She was not known to be a heavy drinker and had no past history of liver
disease. Other than the oral contraceptive pill, she was on no regular
medications.
On examination, her temperature was 37.1 °C. She was tearful and
withdrawn, but alert and orientated. Aggressive fluid resuscitation and
treatment with N-acetylcysteine were initiated.

1 Which one of the following tests, taken the following day, should prompt
referral to a specialist liver unit?
D A I'aracetamol level 50 mg/L
ÿ B AST 856 U/L
ÿ C Albumin 22 g/L
ÿ D pH 7.25
D E Creatinine 185 pmol/L

84
 GASTROENTEROLOGY - QUESTIONS

Case 19

-4 65-year-old lady presented with a 6-month history of intermittent

epigastric pain radiating to the back. For the past 2 weeks she hadnoticed
that her stools hadbecome pale andher urine dark. An ultrasound of her
upper abdomen revealedthat her common bile duct and intrahepatic
ducts were dilated. She hadhada cholecystectomy 15 years previously for
cholelithiasis.
An image from endoscopic retrograde cholangiopancreatography (ERCP)
is shown below.

1 What is the most likely diagnosis?

D A Ampullary carcinoma
D B Retained stones in the biliary tree
ÿ C Pancreatic carcinoma
O D Primary biliary cirrhosis
ÿ E Primary sclerosing cholangitis

85
GASTROENTEROLOGY- QUESTIONS

Case 20

/\ 78-year-old woman was referredto Outpatients for an opinion. She lived

in a nursing home and, along with many of the other residents, hadhadan
attack of diarrhoea 10 weeks previously. However, her symptoms had
persisted andshe was still opening her bowels eight times a day and was
now passing bloody stools. Over the last few days, lesions had been noted
on her legs.

1 What is the lesion shown?

ÿ Erythema nodosum
A
ÿ Pyoderma gangrenosum
B
O C Sweet's syndrome
CD D Dermatitis herpetiformis
D E Acanthosis nigricans

2 What is the most likely diagnosis?

CD A Infective diarrhoea
CD B Carcinoma of the colon
ÿ C Coeliac disease
D D Ulcerative colitis
ÿ E Ischaemic colitis

86
 GASTROENTEROLOGY QUESTIONS

Case 21

A 3 1-year-oldlawyer was referredby his CP who had investigated him for

tiredness. As part of a screen of blood tests he had been found to have
abnormalliver function tests. He had occasionally used intravenous drugs
as a student but hadnot done so recently. He was marriedand had had no
other sexual partners for the last 4 years. Other than feeling tired, he was
asymptomatic. He took no regular medications and drank 40 units of
alcohol a week.
Blood tests were as follows:
Bilirubin 21 umol/L
AST 85 U/L
ALT 165 U/L
ALP 1 12 U/L

Ilepatitis serology:
I lepatitis A IgM negative
I lepatitis A IgG negative

HBsAg positive
HBeAg positive
Anti-HBc antibody positive
Anti HBe antibody negative

Hepatitis C virus antibody negative

1 Which one of the following is not part of the initial management?

I I A Vaccination against hepatitis A
CD B Hepatitis screening for his partner
D C Liver biopsy
i ) D Abstinence from alcohol
ÿ E Treatment with ribavirin

87
GASTROENTEROLOGY - QUESTIONS

Case 22

A 78-year-old retiredbanker was reviewed in the Outpatients Department

after a recent admission with right lower lobe pneumonia. She hadhad
two similar episodes, managed by her CP, over the last 2 years. She had
mild angina for which she was taking aspirin and atenolol. Otherwise she
was fit and well. She smoked 15 cigarettes a day from the age of 20, and
drank 15 units of alcohol per week. Throughout her life, she hadtravelled
widely in Africa and Asia.
Examination revealed no abnormal signs and her blood tests were
unremarkable.
Her plain chest X-ray is shown below.

1 Which of the following is the most likely diagnosis?

ÿ A Tracheo-oesophageal fistula D D Chagas' disease
ÿ B Carcinoma of the lung ÿ E Pharyngeal pouch
Q C Achalasia

88
 GASTROENTEROLOGY - QUESTIONS

Case 23

A 58-year-old Creek lady attended A&E with a 4-week history of

discomfort in the right upper quadrant.
Examination revealed that she was mildly tender in the right upper
quadrant and had 4-cm hepatomegaly. She had a previous laparotomy
scar, having had a duodenal ulcer oversewn 20 years previously.
Liver function tests were normal, as was the full blood count. Her
abdominal X-ray is shown below.

1 What is the most likely diagnosis?

ÿ Porcelain gallbladder
A
ÿ Hydatid disease
B
ÿ C Amoebic liver abscess
D D Pyogenic liver abscess
Q E Retained foreign body from previous surgery

89
GASTROENTEROLOGY - QUESTIONS

Case 24

A 32-year-old psychiatric patient was found to have iron deficiency

anaemia on routine blood testing and was referred for an opinion. She
complained ol anorexia, fullness in her abdomen and, more recently,
vomiting after eating solids. She was not vegetarian andsaid that she ate a
varied diet, although she did suffer from menorrhagia. She hadlost a little
weight recently.
Examination revealed that she had a large mass in her upper abdomen.
This was found to be non-tender, non-pulsatile and not to move on
ventilation. Other than pale conjunctivae and thinning hair, no other signs
were found. Her blood tests confirmed iron deficiency anaemia, but were
otherwise normal.
Her plain abdominal X-ray is shown below.

90
 GASTROENTEROLOGY QUESTIONS

1 Which of (he following is the most likely diagnosis?

ÿ A Bezoar
B Gastric carcinoma
ÿ C Duodenal ulcer
L J D Pancreatic carcinoma
ÿ E Cystocele of the gallbladder

91
GASTROENTEROLOGY - QUESTIONS

Case 25

A I9-year-old woman presented to A&E with abdominal pain and

vomiting. She hada long history of intermittent cramping abdominal pain,
as did her younger brother, and her father had had two laparotomies.
Examination and investigation revealed signs of small-bowel obstruction.
A picture of her mouth is shown below.

1 What is the diagnosis?

ÿ A Hereditary haemorrhagic telangiectasia (HHT)
ÿ B juvenile polyposis
ÿ C Familial adenomatous polyposis (FAP)
ÿ D Peutz-jegher syndrome
ÿ E Cronkhite-Canada syndrome

92
 GASTROENTEROLOGY - QUESTIONS

Case 26

A 55-year-old woman with a known history ofcoeliac disease was

reviewed in Outpatients complaining of watery diarrhoea ten times per
day andabdominal cramping pains of 10 months' duration. There was no
accompanying weight loss. She claimed to have been adhering to her
gluten-free diet andgave no history of foreign travel or changes in her
medication. She took aspirin and digoxin for chronic atrial fibrillation and
ibuprofen for osteoarthritis.

Examination revealed a well-looking lady who was in rate-controlled

atrial fibrillation. No other abnormalities were noted.

Full blood count, electrolytes, serum calcium, immunoglobulins, CRP and

the ESR were normal. IgA anti-endomysial antibodies were negative.

The colonic mucosa looked normal at colonoscopy. A biopsy specimen

taken at the time is shown below.

1 What is the diagnosis?

ÿ A Ulcerative colitis
ÿ B Poorly controlled coeliac disease
ÿ C Coeliac disease-related lymphoma
Q D Ischaemic colitis
ÿ E Collagenous colitis

93
GASTROENTEROLOGY - QUESTIONS

Case 27

A 27-year-old woman recently diagnosed with inflammatory bowel

disease attended A&F. with severe upper abdominal pain. She also had
epilepsy which was difficult to control, requiring recent manipulation of
her drug therapy.
On examination she was tachycardic (1 10 bpm), hypotensive (95/55
mmHg) and had marked epigastric tenderness.
Blood results were as follows:
lib 8.6 g/dL
MCV 85 fL
wcc 13.0 x I07L
Platelets .387 x 10'7L
Sodium 137 mmol/L
Potassium 4.5 mmol/L
Urea 5.4 mmol/L
Creatinine 98 mmol/L
Corrected Ca2' 2.1 gmol/L
Amylase 1635 U/L

1 Which of the following drugs that she is taking is least likely lo be the
cause?
ÿ 6-mercaptopurine
A
ÿ Phenobarbital
B
O C Prednisolone
0 D 5-aminosalicylic acid
0 E Sodium valproate

94
 GASTROENTEROLOGY - QUESTIONS
Case 28
-4 79-year-old man was referred by his GP with a 4-month history of
dysphagia. He was unable to pinpoint the site of his symptoms accurately
but noted that his dysphagia worsened as he ate. At times he would
regurgitate food during his meals, which would temporarily relieve his
symptoms. According to his GP, who had weighed him, he had lost Ikg in
weight over the past 2 months. His medications included
bendroflumethiazide for hypertension and ranitidine, which he took
intermittently for symptoms of gastro-oesophageal reflux disease.

A barium swallow is shown below.

1 What is the diagnosis?

ÿ A Schatzki ring
ÿ B Achalasia
ÿ C Benign oesophageal stricture
ÿ D Pharyngeal pouch
ÿ E Post-cricoid web

95
GASTROENTEROLOGY - QUESTIONS

Case 29

A 17-year-old Turkish girl presentedto A&E with a 4-hour history of severe

abdominal pain. The onset was rapid and without preceding symptoms.
She described no change in her bowelhabit or urinary symptoms. She had
had an appendectomy 6 months previously and an exploratory
laparotomy 2 months ago for similar episodes. At neither operation was
arty abnormality found other than a small amount of peritoneal fluid.

On examination she was pyrcxial at 39.2 "C and tachycardic at 105 bpm.
I ler abdomen was diffusely tender with guarding in the right upper
quadrant. Bowel sounds were reduced. A painful erythematous rash was
noted on the lower limbs.

Investigations were as follows:

Urinalysis Blood +
Hb 13.6 g/dL
MCV 85 fL
WCC 14.8x10'VL
Platelets 387 x 10"/L
CRP 55 mg/L
(S-HCG < 5 U/L

Erect chest X-ray Normal

1 Which of the following is the most likely diagnosis?

ÿ A Ectopic pregnancy
ÿ B Recurrent polyserositis
ÿ C Acute intermittent porphyria
O D Renal colic
0 E Abdominal angina

96
 GASTROENTEROLOGY - QUESTIONS

Case 30

A 27-year-old lady who was 16 weeks pregnant was referredfor an

opinion by the obstetriciansbecause of recurrent vomiting. She hadstarted
vomiting early in her pregnancy and had not responded to treatment with
anti-emetics. She now weighed 5kg less than when she became pregnant.
Nasogastric and nasojejunal feeding were unsuccessful due to recurrent
regurgitation of the tubes. Accordingly, total parenteral nutrition (TPN)
was commenced. She also requiredsupplemental intravenous fluids due
to continued vomiting.

Her blood tests were checked 72 hours after initiating TPN and were as
follows:
Sodium 137 mmol/L
Potassium 2.9 mmol/L
Urea 2.4 mmol/L
Creatinine 69 gmol/L
Corrected Ca2+ 2.2 mmol/L
Phosphate4 0.2 mmol/L
Magnesium 0.4 mmol/L

1 What is the most likely explanation for these results?

D Bloods taken from drip arm
A
C Syndrome of inappropriate ADH secretion
B
ÿ C Inappropriate intravenous fluid replacement
D Refeeding syndrome
C E Vomiting-related electrolyte loss

97
GASTROENTEROLOGY- QUESTIONS

Case 31

A 44-year-oldgentleman with a long history of diarrhoea presented with a

painful lesion on his leg. He hadnoticedwhat he thought was an insect
bite some days previously, which rapidly progressed to the lesion
depicted. He hadstarted feeling unwell with the development of the lesion
anddescribed general malaise and arthralgia.
A picture of the lesion and a barium enema are shown below.

1 What two diagnoses are shown?

D A Pyoderma gangrenosum
ÿ B Crohn's disease
ÿ C Acanthosis nigricans
ÿ D Ulcerative colitis
CD E Ogilvie's syndrome
D F Ischaemic colitis
CD C Erythema nodosum
CD H Erythema multiforme
CD I Colonic carcinoma
CD ) Dermatomyositis
 GASTROENTEROLOGY - QUESTIONS

Case 32

A 55-year-oldlady was admitted via A&E complaining of intermittent

epigastric pain. She hadhad a cholecystectomy Iyear ago for these
symptoms but continued to have pain after the procedure. The pain was
severe, typically came on when she was eating, radiated to the back and
was accompanied by nausea and sometimes vomiting. It tended to last for
several hours and did not vary in intensity. She hadhad five attacks over
the last year.
Blood results at the time of her admission are shown:
Bilirubin 21 pmol/L
AST 100 U/L
ALT 1 1 0 U/L
ALP 1 76 U/L
Amylase 220 U/L

An ultrasound scan showed a moderately dilated common bile duct

(12 mm) but no stones were seen. Consequently, she underwent an
endoscopic retrograde cholangiogram which, again, showed mildly
dilated ducts. A sphincterotomy was performed along with trawling of the
bile duct, again revealing no cause. Post-procedure she developed acute
pancreatitis from which she recovered with conservative management.
Subsequently, her symptoms resolved.

1 Which of the following is the most likely diagnosis?

ÿ A Recurrent biliary stones
CD B Non-ulcer dyspepsia
CD C Chronic pancreatitis
CD D Sphincter of Oddi dysfunction
CD E Primary sclerosing cholangitis

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GASTROENTEROLOGY- QUESTIONS

Case 33

A 56-year-oldgentleman is brought to the hospital after collapsing in the

street. On arrival he is alert but disorientatedandsmells strongly of
alcohol. He complains of a sore tongue.
Examination reveals that he is unkempt and malnourished, with angular
stomatitis and glossitis. A picture of his hands is shown below.

1 What are the changes on his hands most likely due to?
ÿ A Vitamin B,. deficiency
ÿ B Vitamin C deficiency
ÿ C Thiamine deficiency
ÿ D Niacin deficiency
ÿ E Riboflavin deficiency

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 GASTROENTEROLOGY - QUESTIONS

Case 34

A 55-year-oldgentleman attended A&E with haematemesis half an hour

previously. He was visiting the UK from Africa but hadbeen well prior to
presentation. On arrival he was shockedand pale and therefore
underwent upper gastrointestinal endoscopy after adequate resuscitation.
Blood tests on arrival were as follows:
I lb 6.6 g/dL
MCV 65 fL
WCC 6.0 x 10'YL
Platelets 87x10'/L
Albumin 40g/L
Bilirubin 5 pmol/L
AST 12 U/L
ALT 13 U/L
ALP 66 U/L
INR 1.0

Examination of the oesophagus revealed large varices with stigmata of

recent bleeding. No blood was seen but two red worms, about 1 0 mm in
length, were noted adherent to the mucosa in the duodenum.

1 Which two agents is he most likely to be infected with?

ÿ A Trichuris trichiura
ÿ Necator americanus
13
ÿ C Hepatitis B virus
ÿ D Schistosoma haematobium
ÿ E Strongyloides stercora1is
ÿ F Ascaris 1umbricoides
D G Hepatitis C virus
ÿ FT 5c/r istosoma mansoni
ÿ 1 Enterobius vermicularis

101
GASTROENTEROLOGY- QUESTIONS

Case 35

A 45-year-old lady attended A&E with a 4-hour history of acute severe

central abdominal pain that was colicky in nature andassociated with
nausea and vomiting. Other than hypertension, for which she had recently
started a fi-blocker and an angiotensin-converting enzyme inhibitor, she
was fit and well with no past medical or surgical history and no family
history of note.

Her plain abdominal X-ray is shown below.

1 What is the most likely diagnosis?

CD A Ogilvie's syndrome
ÿ B Angio-oedema of the bowel
ÿ C Gallstone ileus
ÿ D Adhesions
CD E Irritable bowel syndrome

102
 GASTROENTEROLOGY -QUESTIONS

Case 36
A 42 -year-old man presented to his CP complaining of lethargy, pruritus,
right upper quadrant discomfort and dry mouth and eyes. Otherwise he
was asymptomatic andhad no previous history of note. He drank 24 units
of alcohol per week.
On examination, he had two-finger hepatomegaly and his spleen was just
palpable. No signs of chronic liver disease were present.

Blood tests were as follows:

Sodium 132 mmol/L
Potassium 4.4 mmol/L
Urea 2.4 mmol/L
Creatinine 70 umol/L
Albumin 34 g/L
Bilirubin 25 umol/L
AST 44 U/L
ALT 41 U/L
ALP 556 U/L
GCT 1021 U/L
Serum LDL cholesterol 3.22 mmol/L
Serum HDL cholesterol 5.56 mmol/L
Serum IgM 6.5 g/L

1 What is the most likely diagnosis?

ÿ A Gallstones
ÿ B Pancreatic carcinoma
ÿ C Primary sclerosing cholangitis (PSC)
ÿ D Primary biliary cirrhosis (PBC)
D E Haemochromatosis

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GASTROENTEROLOGY - QUESTIONS

Case 37
A 65-year-old woman is brought to A&E by her husband, complaining of
upper abdominal and lower chest pain radiating to the back. As part of
their fortieth wedding anniversary celebrations, they hadbeen out for a
large meal at which they hadconsumed more alcohol than they were
normally usedto. On returning home, she hadbecome nauseatedandhad
vomited three times. Concurrently, she developed upper abdominal and
lower chest pain and, subsequently, shortness of breath.
On examination, she was tachycardic at 105 bpm, tachypnoeic at 25
breaths per minute and was pyrexial at 37.8 °C. She had firmness in the
upper abdomen and a plain chest X-ray confirmed the clinical findings of a
left pleural effusion.

1 Which of the following is the most likely diagnosis?

D A Mallory-Weisstear
H B Spontaneous pneumothorax
ÿ C Acute pancreatitis
ÿ D Perforated peptic ulcer
ÿ E Boerhaave syndrome

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 GASTROENTEROLOGY - QUESTIONS

Case 38

A 67-year-old gentleman of Irish descent presented to Outpatients with a

10-month history of right iliac fossa abdominal pain and watery diarrhoea
up to 15 times a day. He hadbeen a heavy drinker in the past, consuming
40 pints of beer a week, but had cut back to Ipint a day for several years.
He had recently noticedthat his symptoms became worse when he drank
alcoholandso had now stopped completely. His wife hadnoticedthat he
hadlost weight recently but he was unable to quantify this. He had never
smokedbut his wife hadnoticedthat he hadhad some attacks ol
wheeziness.
Examination of his abdomen revealed 3-cm hepatomegaly and an
indistinct mass in the right iliac fossa. Urea and electrolytes, liver function
tests and full blood count were normal, but a small-bowel barium
examination revealed a submucosal mass in the ileum.

1 What is the likely diagnosis?

ÿ A Coeliac disease-related lymphoma
D B Chronic pancreatitis
D C Villous adenoma
D D Carcinoid syndrome
D E Immunoproliferative small intestinal disease (IPSID)

1 05
GASTROENTEROLOGY QUESTIONS

Case 39

A 44-year-old woman attended A&F. complaining of shortness of breath

and tiredness. She had recently startedoral treatment for an intensely
itchy, vesicular rash on the elbows, knees, buttocks andback. She also
gave a history of milddiarrhoea andabdominal bloating, and hadlost a
stone in weight.

Her blood results were as follows (RDW, red cell distribution width):
Mb 5.6 g/dl
MCV 90 II
WCC 5.8 x 107L
Platelets 387 x 1071
RDW 22%
Sodium 138 mmol/L
Potassium 4.4 mmol/L
Urea 4.4 mmol/L
Creatinine 99 (.rmol/L
Albumin 32g/L
Corrected Ca2+ 2.0 mmol/L
Bilirubin 30 nmol/L

106
 GASTROENTEROLOGY - QUESTIONS

1 Which two of the following are most likely to be contributing to her

anaemia?
ÿ A Autoimmune haemolysis
ÿ B Drug-related haemolysis
ÿ C Iron deficiency due to malabsorption
ÿ D Vitamin Bi;. deficiency
ÿ E Anaemia of chronic disease
ÿ F Gastrointestinal blood loss
ÿ G Bone marrow suppression
ÿ H Sideroblastic anaemia

107
GASTROENTEROLOGY - QUESTIONS

Case 40

A 47-year-old woman attends Outpatients asking tor advice. She has a

family history of colorectal carcinoma. Her family tree is shown below
(patient arrowed).

Died colorectal Died endometrial

cancer aged 71 cancer
aged 42 years

II.1 11.4
Died 53 years
colorectal colonic
cancer doIvds
aged 36
years

1 What is the most likely explanation for the family's history?

_ A Familial adenomatous polyposis (FAP)
ÿ B Flereditary non-polyposis colorectal cancer
ÿ C Sporadic colorectal carcinoma
ÿ D Peutz-|egher syndrome
_ E Attenuated familial adenomatous polyposis

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 GASTROENTEROLOGY - QUESTIONS

Case 41

A 69-year-old gentleman presented to A&E claiming to have swallowed a

foreign object 2 hours previously. He had a long history of mental health
problems and hadpresented with a similar history in the past. He denied
any dysphagia, odynophagia or abdominal pain, and physical
examination was unremarkable.
His plain abdominal X-ray is shown below.

1 What course of action would you advise?

ÿ A Laparotomy and removal of the object
ÿ B Endoscopic removal of the object
ÿ C Reassure and discharge the patient
ÿ D Monitor with weekly X-rays to ensure passage through the
gastrointestinal tract
ÿ E Metoclopramide or other gastrointestinal stimulants

109
 PSYCHIATRY - QUESTIONS

Case 1

A 52-year-ulcl homeless alcoholic man presented to A&E with a 2-week

history of general malaise, abulia, insomnia and worsening anorexia. For
the last 3 days he had been unable to tolerate alcohol. He also described
recent headache, sweating and palpitations. Ilis CP had prescribed
paroxetine 6 months earlier for depression without benefit, andhe now
presentedseverely depressed and suicidal.

Physical examination revealed signs of chronic liver disease. Sensation lo

pinprick and light touch was reduced in a stocking distribution and his leg
muscles were painful and tender. Tone was mildly raised in the lower
limbs and the reflexes were symmetrically brisk, except at the ankles
where they were absent. Urine drug screen was negative and paracetamol
and salicylate were undetectable. I lis blood results were:

Hb 1 1.9 g/dL
MCV 1 03 fF
wcc 4.5 x 107F
Platelets 1 05 x 10'VL
AFT 74 U/L
Albumin 32 g/L
Sodium 129 mmol/l.
Urea 3.1 mmol/l.

1 What is the most likely diagnosis?

U A Wernicke-Korsakoff syndrome
CD B Alcoholic hallucinosis
ÿ C Central pontine myelinolysis
ÿ D Pellagra
I ) E Paroxetine overdose
ÿ F Paroxetine discontinuation syndrome
CD G Subdural haematoma
ÿ H Delirium tremens
I Chronic alcohol dependency
ÿ ) Korsakoff's syndrome
He was admitted to an acute psychiatric ward and nursed one-to-one
because of ongoing suicidal ideation. Four days after starting on
chlordiazepoxide detoxification he became increasingly disorientated
and confused and was seen responding to auditory hallucinations. He
became convinced that the nurse with him planned to murder him in his
sleep. He was incontinent of urine and faeces. On repeat examination he
was found to be ataxic with extrapyramidal rigidity.

113
PSYCHIATRY - QUESTIONS

2 What additional diagnosis/complication has occurred?

O A Wernicke-Korsakoff syndrome
I 1 B Alcoholic hallucinosis
CD C Central pontine myelinolysis
ÿ D Pellagra
CD E Paroxetine overdose
ÿ F Paroxetine discontinuation syndrome
CD G Subdural haematoma
I.J II Delirium tremens
( I Chronic alcohol dependency
CD J Korsakoff's syndrome

3 What treatment should be instigated immediately?

ÿ A Pabrinex®
U B Chlordiazepoxide
CD C I laloperidol intramuscularly
CD D Clonidine
ÿ E Thiamineintravenously
CD F Olanzapine 10 mg
ÿI G Neurosurgical referral

114
 PSYCHIATRY - QUESTIONS

Case 2
A23-year-old Swedish student was brought to A&E by her boyfriend who
was concernedthat she hadbeen acting strangely for 48 hours. She had
become increasingly agitated and restless, claiming that her flatmate was
monitoring herbehaviour and trying to steal her identity. She hadnot slept
for 2 nights. On two occasions she hadbecome unresponsive, staring
blankly ahead, following which she appeared confused anddisorientated.
She hadvomited twice and was complaining of severe abdominal pain
that she ascribed to menstruation. She had had two similar though less
severe episodes around the time of menstruation in the last 2 months. She
hadbeen well until (> months previously, when she hadbecame depressed
at the time of her end-of-year exams andhadbeen prescribedfluvoxamine
by her CP.
On examination she appeared confused and was disorientated to time.
Abdominal examination revealed central tenderness without guarding.
Other than sinus tachycardia, the respiratory and cardiovascular
examinations were unremarkable. Neurological exam revealed reduced
sensation distally and reduced power on shoulder abduction bilaterally.

Some investigations are performed:

Hb 12.8 g/dL
WCC 1 1.0 x 1 07L
Sodium 127 mmol/L
Potassium 3.8 mmol/l
Urea 4.1 mmol/l
Chest X-rav
/
Normal
CT brain Unremarkable
A lumbar puncture is performed:

Opening pressure 15 cml bO

RBC 2 cells/mL
WCC 4 cells/ml. (all lymphocytes)
Protein 52 mg/L

1 What two things should you do?

(_, A Psychiatric referral 0 t Amylase
O B FFG 0 F Abdominal ultrasound
0 C Toxicology screen U G Gynaecology referral
0 D Urinary porphyrins (J II Abdominal X-ray

115
PSYCHIATRY - QUESTIONS

2 What is the likely diagnosis?

ÿ A Guillain-Barre syndrome
0 B Cycloid psychosis
0 C Pre-menstrual tension
0 D Non-convulsive status epilepticus
0 E Acute intermittent porphyria (AIP)
0 F Methylenedioxymethamphetamine(MDMA, Ecstasy) toxicity

116
 PSYCHIATRY - QUESTIONS

Case 3

A 32-year-old man presents to A&E with his mother, who is concerned

because he has become increasingly contused and agitated. He was
incontinent of urine before she calledthe ambulance. He is unable to give
a history and appears disorientated. His mother says that he has recently
seen a psychiatrist who has prescribedaripiprazole.
On examination he appears sweaty; temperature is 38.6 °C. I le is
lachycardic at 132 bpm and his blood pressure is 180/105 mmHg.
Neurological examination reveals symmetrically raised tone in all four
limbs; the plantars are bilaterally down-going. Pupillary light reflexes are
normal. The investigations show:
1 lb 13.6 g/dL
WCC 12.4 x 10"/l
Neutrophils 9. 1 x 1 07L
Lymphocytes 2.0 x 1 0'/L
Platelets 155 x 107L
Sodium 135 mmol/L
Urea 7.8 mmol/L
Creatinine 99 pmol/L
ALT 78 U/L
vG 1 299 U/L

1 What is the most likely diagnosis?

O A Catatonic schizophrenia
ÿ B MDMA (Ecstasy) toxicity
0 C Parasagittal meningioma
0 D Neuroleptic malignant syndrome
.) E Serotonin syndrome
0 F Delirium tremens
0 G Tardive dyskinesia
0 H Acute dystonic reaction

2 What is the next investigation that you would perform?

0 A Psychiatry referral
'
O B CT brain
0 C Lumbar puncture
0 D Creatine kinase
0 E Urine drug screen
O F Blood culture

I 17
PSYCHIATRY - QUFSTIONS

3 Which two treatments are most appropriate?

ÿ A Lorazepam
ÿ I? Intramuscular haloperidol
H C Dantrolene
I I D Procyclidine
ÿ E Naloxone
ÿ F Bromocriptine
ÿ G Neurosurgical referral

118
 PSYCHIATRY - QUESTIONS

Case 4

A 36-year-old artist presented to A&F. with a friend who was concerned

that she hadbeen acting strangely and had appeared intermittently
confused over the last 3 days. She said that she hadbeen feeling
increasingly anxious andrestless over the last week and had been to the
health food store to buy some St lohn's wort to pick her up. Her only other
medication is venlafaxine prescribed by her CP. For 2 days she had been
feeling nauseatedand had developed diarrhoea.
On examination she was mildly disorientated in time, was shivering and
appeared restless. She was tachycardic at 120 bpm and her blood pressure
was raised at 150/95 mmHg. Temperature was 37.6 °C. Neurological
examination revealed a fine tremor in the upper limbs and multifocal
myoclonus. Reflexes were symmetrically brisk, plantars down-going.
There was no neck stiffness. Blood tests were unremarkable.

1 What is the most likely diagnosis?

ÿ A Neuroleptic malignant syndrome
ÿ B Serotonin syndrome
ÿ c: Delirium tremens
ÿ D Tardive dyskinesia
ÿ E Akathisia
ÿ F SSRI discontinuation syndrome
ÿ G New variant C)D

119
 RENAL MEDICINE - QUESTIONS

Case 1

A 38-year-oldgentleman with a 12-year history of AIDS, with a good

response to therapy, was admitted with a 12-day history of weakness,
nausea, dysuria, myalgia and decreased urine output. His last CD4
lymphocyte count was 368 x W'/L (normal range 500-900). The current
medications included didanosinc, stavudine, atorvastatin,
trimethoprim-sulfamethoxazole, and he hadbeen commenced on
indinavir.
On examination lie was afebrile, pulse 1 00 bpm and regular,
BP 1 76/99 mrnHg, the JVP was not elevated; the chest and abdominal
examinations were normal.
Investigations:
Mb 13.5 g/dL
WCC 6.7 x I07I
Platelets 200 x 1071
Sodium 1 35 mmol/L
Potassium 5.2 mmol/l
Chloride 102 mmol/L
Bicarbonate 16 mmol/L
Urea 29.2 mmol/L
Creatinine 765 pmol/L
Bone profile Normal
Creatine kinase 1 00 U/L
ANCA Negative
Anti-GBM Negative
Hep B/hep C Negative
ASOT Negative
Cultures of blood/urine/sputum were negative.

1 Which one of the following medications is the most likely cause of his
acute renal failure?
ÿ Didanosine
A
ÿ Stavudine
B
Q Indinavir
C
L) D Atorvastatin
ÿ E Trimethoprin-sulfamethoxazole

123
RENAL MEDICINE- QUESTIONS

2 Which of the following investigations will be most helpful in making the

diagnosis?
O A Native renal biopsy
D B Renal ultrasound scan
Q C Urine for crystals
D D X-ray studies of kidneys, ureters, bladder (KUB)
ÿ E Serum immunoglobulins

124
 RENAL MEDICINE - QUESTIONS

Case 2

A 28-year-old Somalian lady presented to A&E with a 3-week history of

generalised weakness, anorexia, decreased appetite, and weight loss. She
was noted to be increasingly short of breath andhad intermittent
headaches. She worked as a cleaner and has been in the UK ford years.
She was unable to give a sexual history. There was no history of blood
transfusions.
On examination she appeared cachectic, afebrile, pulse 80 bpm and
regular, BP 130/80 mmHg, JVP not seen. There was no peripheral oedema.
Chest examination was normal. Fundoscopy revealed grade 2
hyperlensive retinopathy. The remainder of examination was normal.
Investigations:
Hb 9.2 g/dL
wee 4.1 x 107L
Platelets 1 00 x 107L
Blood film Microcytosis
Sodium 138 mmol/L
Potassium 3.2 mmol/L
Urea 1 8 mmol/L
Creatinine 205 pmol/L
Tola I protein 58g/L
Albumin 18g/L
LFTs Normal
Bone profile Normal
Urine microscopy Intact red blood cells/granular casts
Blood/urine culture Negative
CXR Normal
ECG Normal
Renal ultrasound scan Highly echogenic kidneys
Right kidney 13.5 cm; left kidney 14 cm
She underwent a native renal biopsy.

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RENAL MEDICINE - QUESTIONS

1 What is most likely diagnosis?

D A Primary focal segmental glomerulosclerosis
' I B Schistosomiasis
_I C HIV-associated nephropathy (HIVAN)
ÿ D Heroin-associated nephropathy
ÿ E Malignant hypertension

126
 RENAL MEDICINE - QUESTIONS

Case 3

A 70-year-old while man with a history of intermittent microscopic

haematuria presented with generalised fatigue, cough, and vague
abdominal pain and diarrhoea. He has a history of hypertension and was
on irbesartan. Baseline renal function was normalwhen checked by his
CP 3 weeks previously.
Initial investigations:
Hb 7.8 g/dL
Haematocrit 0.4
Platelets 98 x 10'VmL
Creatinine 250 umol/L
Amylase 150 U/L
LFTs Normal
Urine microscopy was not done on admission.
Ultrasound scans of abdomen and pelvis were normal.
The chest radiograph is as below.

127
RENAL MEDICINE - QUESTIONS

He was treated with ciprofloxacin for a presumed chest infection. He then

developed acute ischaemic bowel requiring resection, with non-specific-
pathological findings. The hospital course was complicated by
hypotension and multi-organ failure. The creatinine rose to 636 pmol/L
with anuria; haemodialysis was initiated.
Urine microscopy Numerous red blood cells
Protein excretion 3 g/24 h
ANA, ANCA Negative
HBsAg Negative
HCV Negative
Cryoglobulins Negative
C3 107 mg/dL (NR 65-1 90 mg/dL)
C„ 38 mg/dL (NR 15-50 mg/dL)
Protein eleclrophoresis Normal pattern
Renal biopsy was performed which showed crescentic glomerulonephritis
with linear IgG staining on immunofluorescence.

1 What is the most likely diagnosis?

CD A Post-streptococcal glomerulonephritis
CD B Haemolytic uraemic syndrome
CD C Acute pyelonephritis
CD D Microscopic polyangiitis
CD P Anti-glomerular basement membrane disease

128
 RENAL MEDICINE - QUESTIONS

Case 4

A 28-year-old man with Alport's syndrome received a pre-emptive living

relatedrenal transplant from his mother. He has excellent primary graft
function and the baseline creatinine was 102 umol/L. Three months later
hepresented with a I-week history of decreased urine output with a raised
creatinine of 188 pmol/L; the biopsy did not show evidence of acute
rejection.
Urine microscopy showed dysmorphic red blood cells. He became
progressively oligo-anuric and became dialysis-dependent.

1 What is the most likely diagnosis?

D A Anti-glomerular basement membrane disease
O B Aspergillus pneumonia
O C Post-transplant lymphoproliterative disorder
D D Mycoplasma pneumonia
ÿ E Wegener's granulomatosis

129
RENAL MEDICINE - QUESTIONS

Case 5

A 33-year-old white man was admitted with a 1-week history of rash,

pyrexia, generalised weakness and decreased urine output.
On examination he was obese, with a temperature of 38.5 "C, BP 156/70
mmHg. He had nail-fold vasculitic skin lesions. On auscultation he had a
soft systolic murmur. Abdominal examination was limited given his size,
but unremarkable.
Initial investigations revealed:
Hb 9 g/dL
WCC 18.5x1071.
Neutrophils 16.4x1071.
Platelets 80 x 107L
Creatinine 336pmol/L
Urine microscopy Red cell casts
Hepatitis B Negative
Hepatitis C Negative
ANCA/GBM Negative
Cryoglobulins Positive
ASOT Negative
Protein electrophoresis Negative
Ultrasound scan of the abdomen showed an I I -cm spleen.
Renal biopsy was not performed, as it was not technically possible.

1 What is the most likely diagnosis?

CD A Microscopic polyangiitis
CD B Infective endocarditis
CD C Acute pyelonephritis
L. D IllV-associated nephropathy (I IIVAN)
ÿ E Renal tuberculosis

130
 RENAL MEDICINE - QUESTIONS

Case 6

A 50-year-old man presented with a 4-month history of hypertension,

headaches, and impaired vision. Two weeks ago he notedblood in his
urine. His medical history was significant - he hada left nephrectomy
16 years previously.
The following is the MRI scan of his abdomen and brain:

>

,
_ . /?

KV 120
HA 240
II 0.75
CI 0.0
M 5.0/7.5
202 11/33
AC 50 io « n r. W 420
121 1020 C 41

131
RENAL MEDICINE - QUESTIONS

1 What is the diagnosis?

O A Autosomal dominant polycystic kidney disease (ADPKD)
CD B Autosomal recessive polycystic kidney disease (ARPKD)
ÿ C Tuberose sclerosis (TSC)
CD D von Hippel—Lindau disease
ZD E Histiocytosis X

132
 RENAL MEDICINE - QUESTIONS

Case 7

A 50-year-old white woman presented to her CP with a 2-week history of

nausea, vomiting, and anorexia. She had mild epistaxis and scant
haemoptysis for the last 6 to 8 months, with three episodes of sinusitis,
treated with antibiotics andinhaled steroids. Her serum creatinine on
presentation was 144 umol/L with protein++ andblood+++. Urine
microscopy revealedgranular casts and dysmorphic red bloodcells. She
was referred to the hospital medical team the next day when her creatinine
was 175 umol/L.
The blood pressure was 1 60/98 mmHg, with no rashes or other findings on
physical examination-
Investigations:
Creatinine 256 umol/L
Haematocrit 0.36
Platelets 300x1071.
WCC 6.1 x 10'VL
ANA Negalive
C3 71 mg/dL (NR 65-1 90 mg/dL)
C, 37 mg/dL (NR 1 5-50 mg/dL)

1 What is the most likely diagnosis?

ÿ A pANCA-positive vasculitis
ÿ B cANCA-positive vasculitis
CD C Lupus nephritis
CD D Post-streptococcal glomerulonephritis
ÿ E Henoch-Schonlein purpura (HSP)

133
RENAL MEDICINE - QUESTIONS

Case 8

A 72-ycar-old Bangladeshigentleman with a new diagnosis of type 2

diabetes, presented with a 3 -week history of leg oedema. His past medical
history includes hospitalisation after a road traffic accident 20 years ago in
Bangladesh and stable angina. There was no history of retinopathy or
neuropathy. Current medications include aspirin 75 mg, atorvastatin
20 mg, amlodipine 5 mg once daily, andisosorbide mononitrate SK 60 mg
once a day. His diabetic control with dietary modification has been
satisfactory with an HbAu of 6.2%.
Investigations:
Creatinine 68 pmol/L
Bilirubin 5 pmol/L
AIT 30 U/L
ALP 98 U/L
yCT 45 U/L
Total protein 32 g/L
Albumin 18g/L
Cholesterol 9.8 mmol/L
Urine microscopy Granular casts
Urine protein 14.2 g/day

Hepatitis serology:
B e antigen Negative
B core IgG antibody Positive
B surface antigen Positive
C antibody Negative
Renal biopsy was performed and is shown opposite.

134
 RENAL MEDICINE - QUESTIONS

1 What is the most likely diagnosis?

[ I Renal TB
A
0 Mesangiocapillary glomerulonephritis (MCGN)
B
ÿ C Minimal-change disease
0 D Diabetic glomerulosclerosis
O E Membranous nephropathy

135
RENAL MEDICINE - QUESTIONS

Case 9

A 68-year-old Ghanaian gentleman with a 10-year history of type 2

diabetes presented with a 3-week history of generalised oedema. In spite
of insulin treatment, his diabetes has been poorly controlled. He has
backgroundretinopathy. Investigations revealednormal renal function;
albumin 12g/L; negative ANA, ANCA, GBM, HBsAg, hepatitis C antibody,
cryoglobulins and serum electrophoresis; 24-hour urine protein excretion
was 15.6g.
He underwent a renal biopsy.

1 What is the most likely diagnosis?

D Focal segmental glomerulosclerosis
A
ÿ Membranous nephropathy
B
ÿ C Light-chain disease
ÿ D Diabetic glomerulosclerosis
C E Minimal change disease

136
 RENAL MEDICINE - QUESTIONS

Case 10

-4 19-year-old man presented with a 2-day history of a painful rash,

constipation, lethargy andgeneralised body pain. He has no significant
past medical history apart from hospitalisation as child for peritonitis
secondary to a rupturedappendix.

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Investigations:
Creatinine 1 62 pmol/L
LFTs Normal
FBC Normal
Urine microscopy Red cell casts
ANCA Negative
ASOT Normal
Hepatitis B/C Negative

1 What is the diagnosis?

D A IgA nephropathy
CD B Infective endocarditis
ÿ C Henoch-Schonlein purpura (HSP)
ÿ D Erythema nodosum
CD E Polyarteritis nodosa

137
RENAL MEDICINE - QUESTIONS

Case 11

-4 24-year-old South Asian woman presented with acute onset of left-sided

flank pain with microscopic haematuria. She had a KUB X-ray performed.
She has a history of recurrent urinary tract infections since childhoodand
in the past was investigated and treated by a urology specialist. Her
maternal first cousin is on peritoneal dialysis for end-stage renal disease.

Her investigations:
Creatinine 96 umol/L
Calcium 2.48 mmol/L
Phosphate 1.02 mmol/L
Albumin 40 g/L
Urine protein 0.5 g/24 h
Creatinine clearance 68 mL/minute
24-h urine calcium 10 mmol (NR < 7.5 mmol)
24-h urine oxalate 1 .4 mmol (NR < 0.36 mmol)
24-h urine urate 3.2 mmol (NR < 4.5 mmol)

138
 RENAL MEDICINE - QUESTIONS
1 What is the most likely diagnosis?
CD A Primary hyperoxaluria
CD B Primary hyperparathyroidism
CD C Secondary hyperparathyroidism
CD D Nephrogenic diabetes insipidus
CD E Surreptitious antacid ingestion

139
KLNAL MEDICINE - QUESTIONS

Case 12

A 37-year-old woman presents with a 2-week history of malaise, bruising,

and alteredbowel habit. She has nopast medical history of note and is on
no medications. Systemic examination is unremarkable. Urine output for
the past 2 hours was 180 mL.
Investigations:
Hb 6.2 g/dL
Ilaematocrit 0.24
Platelets 56 x 10"/L
Blood film Fragmented red cells
Urea 14 mmol/L
Creatinine 236 pmol/L

1 What is the best treatment option?

0 A Transfusion with packed redcells to aim for a haemoglobin of 10 g/dL
0 B Intravenous vitamin K
ÿ C Intravenous tranexamic acid
0 D Intravenous fresh frozen plasma
I ) E Ilaemodialysis

140
 RENAL MEDICINE QUESTIONS

Case 13

A 44-year-old man has been referred Io the nephrologists with a serum

creatinine of 210 iimol/L. He has a 15-year history of osteoarthritis . One
year ago he was diagnosed with diabetes mellitus andessential
hypertension. His current medications include ramipril 10 mg, aspirin
75 mg, diclofenac 150 mg and atorvastatin 10 mg daily.
On examination his BP was 1 10/70. Systemic examination was normal.
Investigations:
Hb 1 0.9 g/dL
WCC 7.2 x 10'VL
Platelets 210x10"/L
Sodium 1 38 mmol/l
Potassium 4.2 mmol/l.
Urea 14.2 mmol/l.
Creatinine 224 pmol/L
Calcium 2.28 mmol/L
Phosphate 1 .05 mmol/L
Albumin 38g/L
I lbA„ 5.5%
ECC Normal
Urine protein 0.9 g/24 h
Renal ultrasound scan Unobstructed echogenic kidneys
Right kidney 9.4 cm; left kidney 8.8 cm

1 What is the most likely cause of his renal impairment?

D A Renovascular disease
D B Hypertensive nephrosclerosis
O C Analgesic nephropathy
O D Herbal nephropathy
O E Diabetic nephropathy

141
RENAI MEDICINE QUESTIONS

Case 14

A 66-year-oldgentleman on peritoneal dialysis for end-stage renal failure

presents with a 3-month history of tiredness secondary to anaemia, in spite
of increasedsubcutaneous erythropoietin (EPO) therapy.
Investigalions:
HI) 6.2 g/dL
WCC 6.2 x I0''/L
Differential WCC Normal
Platelets 200x107L
Haematocrit 0.2
MCV 80 fl
Reticulocyte count 0%
Faecal occult bloods Negative
Colonoscopy Normal
Upper gastrointestinal endoscopy Normal
Haptoglobins Normal

1 What is the most likely cause of his anaemia?

L J A Hypothyroidism
IJB Myelodysplasia
ÿ C Myelofibrosis
[ ,
D Pure red cell aplasia
U E Chronic lymphocytic leukaemia

142
 RENAL MEDICINE QUESTIONS

Case 15

A 34-year-oldgentleman with chronic renal failure is seen in the

Nephrology Clinic. He is asymptomatic. His current medications include
atenolol 100 mg once daily, ramipril 10 mg once daily, alfacalcidol 0.25
micrograms once daily, Calcichew"' 1 tablet with meals anda
multivitamin preparation.
Investigations:
Hb 9 g/cIL
Haematocrit 0.3
MCV 80 t'L
Urea 21 mmol/L
Creatinine 423 jimol/L
8.5 pmol/l
Ferritin 14 ug/L

1 How will you next treat his anaemia?

CD A Oral ferrous sulphate

[ I B Intravenous iron
CD C Intravenous erythropoietin
CD D Red cell transfusion
CD E Subcutaneous erythropoietin

1 43
DERMATOLOGY - ANSWERS

Chapter One Answers

Case 1
1 B Hypocalcaemia
This patient has lupus pernio, a cutaneous feature of sarcoidosis. Lupus
pernio causes violaceous infiltrated nodules and plaques, usually on the
nose. There may he associated swelling and ulceration and crusting of
the nasal vestibule.
Cutaneous features of sarcoidosis can be classified as acute, subacute or
chronic:
• Acute changes:
erythema nodosum
papular eruption
scar sarcoid - sarcoid localises to previous sites of trauma
• Subacute changes:
annular sarcoid
nodular sarcoid
angiolupoid sarcoid - rare; usually occurs in women; periorbital,
soft, domed, orange-red swellings
• Chronic changes:
plaque sarcoid
lupus pernio
scarring alopecia.
Lupus pernio lends to be associated with other forms of chronic fibrotic
sarcoidosis. These include:
• Bone cysts - radiolucent, usually in the hands and feet
• Chronic polyarthritis - usually involving ihe small bones of the hands
and feet
• Respiratory tract sarcoidosis - classically this causes a restrictive
pattern on pulmonary function tests
• Lacrimal gland swelling - Mikulicz syndrome, ie bilateral swelling of
the lacrimal and salivary glands. Sarcoid is one cause of this
• Renal sarcoid
• Hypercalcacmia.

Case 2
1 A Discoid lupus erythematosus
This is a picture of scarring alopecia.

146
 DERMATOl OGY - ANSWERS

Alopecia can either be scarring or non-scarring, and focal or diffuse.

Scarring alopecia is characterised by permanent hair loss with loss ot the
follicular orifices.
Causes of scarring alopecia are:
• Discoid lupus erythematosus
• Lichen planopilaris - a subtype of lichen planus. The patient often has
typical lesions of lichen planus - itchy, papules over the volar aspect
of the wrists with white streaks over the buccal mucosa and nail pitting
• Sarcoidosis
• Dissecting cellulitis of the scalp - classically occurs in young black
men. This causes nodules and alopecia over the occiput. Ingrowing
hairs and clipping the hair very short are thought to exacerbate this
condition
• Follicular mucinosis - associated with cutaneous T-cell lymphoma.
Causes of a focal non-scarring alopecia are:
• Tinea capitis -scalp ringworm. Common in young children. The scalp
is often scaly loo
• Alopecia areata - an autoimmune disorder; associated with an
increased incidence of vitiligo and thyroid disease. It typically causes
patchy hair loss with 'exclamation mark hairs' at the periphery - these
are formed by hairs that fracture at the distal end and taper and lose
pigment proximally, so look like an exclamation mark. Usually it is
restricted to the scalp but may affect any site of body hair. There is
often spontaneous regrowth
• Trichotillomania - pulling of hair or use of traction in styling.
Causes of a diffuse non-scarring alopecia are:
• Androgenetic alopecia inherited tendency. Androgen-dependent.
Men are affected more than women; in women it is a rare but
important allusion to the possibility of an androgen-secreting tumour.
The typical pattern of thinning is at the frontal regions and crown
• Telogen effluvium - often follows major illness, stress or operation,
and will regrow
• I lypo- or hyperthyroidism
• Iron deficiency
• Zinc deficiency
• Some oral contraceptive pills
• Pregnancy.

Case 3
1 D Pernicious anaem ia
This is vitiligo - an acquired disorder of depigmentation characterised by

147
DERMATOLOGY - ANSWERS

loss of melanocytes from the epidermis. II typically presents as a

hypopigmented patch with a sharp border. It oflen spreads to involve the
body symmetrically. The pathogenesis is uncertain although there is an
association with autoimmune disease and this is thought to be relevant.
A number of conditions occur in association with vitiligo. These include:
• Thyroid disease - Graves' disease (hyper-, hypo- or euthyroid),
atrophic thyroid failure and Hashimoto's thyroiditis
• Type! diabetes mellitus
• Addison's disease
• Pernicious anaemia
• Myasthenia gravis
• Hypoparathyroidism
• Alopecia areata
• Morphoea.
Treatment of vitiligo is unsatisfactory. Some cases spontaneously resolve.
Treatment with potent topical corticosteroids or I'UVA phototherapy
helps some.
Other causes of a depigmented patch include:
• Tinea corporis - usually overlying fine scale, post-inflammatory
pigmentation, border less distinct
• Hypopigmented mycosis fungoides - cutaneous T-cell lymphoma (but
one would see multiple patches and usually on the trunk)
• Leprosy

Case 4
1 B Bendroflumethiazide
This is the distribution of a photosensitive drug eruption. The most
common photosensitising drugs are:
• Thiazide diuretics
• Phenothiazines egchlorpromazine, promethazine
• Sulphonamides
• Oral hypoglycemics- tolbutamide, chlorpropamide
• Tetracyclines
• Griseofulvin
• Amiodarone- chronic use leads to slate-grey pigmentation.
Beta-blockers, lithium and NSAIDs may exacerbate psoriasis.
Codeine phosphate can cause a fixed drug eruption. This is a round itchy
erythematous oedematous patch, with or without blistering, which fades
to leave a brown discoloration of the skin. Re-challenge with the drug
will cause the rash to recur in the same place. Other drugs which
commonly cause a fixed drug eruption are:
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 DERMATOLOGY - ANSWERS

• Barbiturates
• Sulphonamides
• Tetracyclines
• Salicylates
• NSAIDs.
Phenytoin commonly causes a drug rash. It is a frequent cause of
erythema multiforme. In addition, it may cause the phenytoin
hypersensitivity syndrome. This is characterised by a rash (often
non-specific or morbilliform), fever, lymphadenopathy, hepatomegaly,
eosinophilia and abnormal LFTs. Phenytoin hypersensitivity can be fatal,
and there is cross-reactivity with carbamazepine, gabapentin and
phenobarbital. The only 'sate' anti-epileptic drug to use in this situation
is sodium valproate. In addition, first-degree relatives have a higher
chance of developing the syndrome with these drugs.

Case 5
1 A Phenytoin treatment
This is a fissured/scrota Itongue. It is associated with:
• Geographical tongue - common and a normal variant. It affects 1% of
the population; 50% also have a fissured tongue
• Granulomatous infiltration:
Sarcoid
Crohn's disease
Melkersson-Rosenthal syndrome -triad of labial oedema, fissured
tongue and recurrent unilateral facial palsy
Trisomy 21 .
Phenytoin and ciclosporin characteristically cause gingival hyperplasia.

Case 6
t E Ankylostoma braziliense
This is a picture of cutaneous larva migrans. This is a self-limiting
cutaneous eruption caused by the larvae of roundworms. Ankylostoma
braziliense is the most common agent. Cutaneous larva migrans has a
worldwide distribution but is especially prevalenl in Central and
Southern America. Dogs and cats carry the roundworm. Beaches are a
common reservoir.
Eggs are passed in the faeces of infected animals and then hatch in soil or
sand. The larvae easily penetrate skin, often causing a non-specific itchy
dermatitis at the time. Migration of larvae usually occurs within a week,
with the production of a wandering, thread-like, intensely pruritic,

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DERMATOLOGY - ANSWERS

erythematous track. The larvae travel at a speed of a few mm to 2 cm

daily.
The cutaneous eruption can be accompanied by breathlessness, transient
pulmonary infiltrates, fever and eosinophilia - Loeffler's syndrome.

Treatment is with ivermectin 12 mg stat or albendazole 400 mg/day for

3 days.
Strongyloides stercoralis causes larva currens. Although this has a similar
appearance, it migrates through the skin at a much faster rate - up to
10 cm/hour.

Toxocara canis causes toxocariasis -visceral larva migrans. Cutaneous

manifestations include generalised pruritus and urticaria. Other features
are eosinophilia, cough, breathlessness, muscle pains and
hepatomegaly.
Sarcnples scabei is the mite which causes scabies. Scabies is an intensely
pruritic eruption, usually affecting the web spaces of the fingers and volar
aspect of the wrist. It can produce a generalised papular eruption or
nodules if left untreated.
Schistosoma haematobium causes schistosomiasis.

Case 7
1 A Spironolactone
This woman has facial hirsutism. Hirsutism is the abnormal growth of
terminal hair in androgen-sensitive areas such as the moustache and
beard regions. The causes of this arc:
• Ovarian:
PCOS
ovarian hyperthecosis
ovarian tumours
• Adrenal:
congenital adrenal hyperplasia
Cushing's disease
adrenal tumours
• I lyperprolactinaemia
• Acromegaly
• Androgen therapy, eg anabolic steroids
• Idiopathic - can be racial variation.
Appropriate investigations include:
• Testosterone and sex hormone-bindingglobulin

150
 DERMATOLOGY - ANSWERS

• LH/FSH
• Androstenedione
• Dehydroepiandrosterone sulphate (DHEAS)
• Follicular phase 17-hydroxyprogesterone
• Prolactin
• Fasting glucose
• Ultrasound ovaries.

Treatment options are:

• Anti-androgen therapy:
oral contraceptive
cyproterone acetate
spironolactone
finasteride (5-a reductase inhibitor)
dexamethasone (in CAH)
• Physical hair removal
• Waxing, shaving, electrolysis, laser.
Case 8
1 A Fasting glucose
This is acanthosis nigricans. The characteristic clinical features are of
hyperkeratosis, pigmentation, papillomatous elevations and a velvety
texture to the skin. The sites most commonly involved are the axillae,
neck, anal margin and groin flexures. It may also affect the submammary
region, umbilicus and rarely the entire skin surface. A skin biopsy is not
usually required as this is a typical appearance.
The causes of acanthosis nigricans are:

1 The metabolic syndrome- acanthosis is a marker of insulin

resistance which visceral obesity may be a cause of. Hyperglycaemia
(impaired fasting glucose, impaired glucose tolerance or frank type 2
diabetes mellitus), dysplipidaemia (elevated LDL and triglycerides
and low HDI ), hypertension, hyperuricaemia, elevated plasminogen
activator, increased coronary artery disease and PCOS can all be
features of the metabolic syndrome. Treatments that improve insulin
sensitivity are weight loss and exercise, and hypoglycaemic agents.
Insulin sensilisers, eg metformin and thiozoladinediones, are
particularly attractive for treatment of the metabolic syndrome.
2 Hereditary benign acanthosis nigricans -this is determined by an
irregular dominant gene. It is not associated with any endocrine
abnormality.
3 Drug-induced - nicotinic acid, fusidic acid, stilbestrol and the oral
contraceptive pill.

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DLRMATOLOGY - ANSWKRS

4 Malignant - usually in association with adenocarcinoma but also

TCC bladder and SCC bronchus. Acanthosis developing after the age
of 40 years is more suspicious of malignancy. Its occurrence in
slender elderly people is highly suggestive of internal malignancy.
There is also condition called 'Pseudoacanthosis nigricans'. This is a
benign and reversible complication of obesity. This is more commonly
seen in skin types IV and V.

Case 9
1 B Dermatomyositis
These are Gottron's papules, a pathognomonic sign in dermatomyositis.
Other typical cutaneous manifestations of dermatomyositis include:
• Heliotropic (violaceous) inflammatory rash of the eyelids. There may
also be periorbital oedema
• Erythema of the face, neck and upper trunk, which is often
photosensitive
• Calcinosis
• Raynaud's phenomenon.
Extracutaneous features of dermatomyositis are:
• Muscle weakness - proximal myopathy, dysphagia, dysarthria
• Pulmonary fibrosis and pulmonary hypertension
• Myocarditis and myocardial fibrosis - conduction defects, cardiac
failure
• Associated malignancy (in 10-50% cases) - lung, breast, ovarian,
stomach, renal, testis.
Diagnosis is confirmed by:
• Skin biopsy
• Muscle biopsy
• Muscle MRI, which can replace the need for muscle biopsy and can
identify patchy involvement (which can lead to a false-negative
muscle biopsy).
• EMG
• ANA-positive in > 90% and anti-Jo- 1 in 40%.
Other useful investigations include:
• EGG
• CXR.
This patient also requires chest CT and/or bronchoscopy.
The rash improves when an underlying malignancy is treated. Other

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 DERMATOLOGY - ANSWERS

therapies include:
• Systemic corticosteroids
• Hydroxychloroquine
• Methotrexate
• Intravenous immunoglobulin
• Sun protection.

Case 10
1 C Pulsed intravenous methylprednisolone
This is a classic picture of pyoderma gangrenosum. Pyoderma
gangrenosum is a destructive, necrolising, non-infective ulceration of the
skin. It presents as an ulcer with an undermined, overhanging purple
edge. There may be associated surrounding inflammation and necrosis.
Most cases of pyoderma gangrenosum are associated with an underlying
disease process. These include:
• Gastrointestinal disease - ulcerative colitis, Crohn's disease, peptic
ulcer disease
• Liver disease chronic active hepatitis, primary biliary cirrhosis,
sclerosing cholangitis
• Joint disease- rheumatoid arthritis, ankylosing spondylitis,
osteoarthritis, polychondritis, Behcet's syndrome
• Blood disorders - leukaemias, myelomas, lymphomas
• Neoplasia - carcinoma of the colon, prostate, breast or bronchus and
neuroendocrine tumours (carcinoids).

Pyoderma gangrenosum is often precipitated by trauma or surgery.

Surgical debridement exacerbates the condition.
Treatment is with immunosuppressive therapy. Initially this involves
high-dose steroids. Ciclosporin, azathioprinc and methotrexate are often
used. More recently, cytokine blocking agents (infliximab) have been
used with success.

Case 11
1 D Cutaneous leishmaniasis
This is a typical ulcer of cutaneous leishmaniasis. Leishmaniasis is
transmitted by the sandfly. It can be cutaneous or visceral. Cutaneous
leishmaniasis can be of 'Old World' or 'New World' types.

I Old World cutaneous leishmaniasis

Caused by Leishmania major, L. tropica, L. aethiopica, L. infantum,

1 53
DtRMATOI OCY - ANSWERS

and is endemic in the Eastern Mediterranean, Middle East, Southern

Russia. There is some leishmaniasis in China, India and North Africa.
The incubation period is approximately 2 months.
It produces one or more lesions, usually on exposed sites. The
sequence of disease is of a nodule which crusts, then forms an ulcer
that heals slowly with scar formation.
2 New World mucocutaneous leishmaniasis
Caused by L. brazilicnsis, L. mexicana, and is endemic in South and
Central America, especially in forest and jungle areas after the rainy
season. It produces an ulcer, which may be verrucous ±
lymphadenopathy. It can be aggressive and destroy cartilage.
40% of those affected develop mucosal lesions, usually in the nasal
mucosa. It may present 2 years after infection.
Diagnosis:
• It is important to consider in travellers returning from endemic areas
• Smear of exudate from the sore: Giemsa or Wright's stain demonstrate
the parasite
• Needle aspiration
• Culture
• Histology of an ulcer typically shows Leishman-Donovan bodies.
Treatment:
Sodium stibogluconate 20 mg/kg/day for 2-3 weeks.
Visceral leishmaniasis (kala-a/ar):
• L. donovani is usually the responsible agent
• Present with fever, fatigue, cough, diarrhoea, epistaxis, splenomegaly,
hepatomegaly, lymphadenopathy and hyperpigmentation of the skin.

Case 12
1 E Lichen planus
This is lichen planus. It characteristically causes small, flat-topped,
violaceous papules over the wrists, ankles and genitalia. White lacy lines
called 'Wickham's striae' are often seen within lesions. Oral
involvement is common - usually white patches or plaques on the
buccal mucosa, but sometimes erosive changes are seen. Nails typically
have pitting, longitudinal ridging and distal splitting. Scalp involvement
can be seen, with scarring alopecia which is then known as 'lichen
planopilaris'.
Risk factors for lichen planus include:

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 DERMATOI OGY - ANSWERS

• Chronic liver disease, especially hepatitis C

• Drugs- antimalarials, gold, penicillamine
• Colour film developers.
Treatment:
• Avoid predisposing factors
• Topical corticosteroids
• PUVA/UVB phototherapy
• Systemic immunosuppressants - including prednisolone, cyclosporin,
and azalhioprine-are required in some.
Scabies typically causes itchy papules too, but classically involves the
finger web spaces. After 6 months' scabies infestation, one would expect
to see scabetic nodules.

Secondary syphilis produces a non-itchy eruption over the upper

extremities and trunk, with special predilection for the palms.
Eczema can produce itchy papules anywhere, but the Wickham's striae
and underlying hepatitis C make lichen planus much more likely in this
case.
Psoriasis is not itchy.

Case 13
1 D Leprosy
The combination of a hypopigmenled patch and ulnar nerve palsy is
compatible with a diagnosis of leprosy, of borderline type.
Tuberculoid leprosy (TL) -> borderline leprosy -> lepromatous leprosy (LL)
Skin lesions:
• Sharply defined plaques
• Hypopigmented
• Anaesthetic skin lesions
• Symmetrical nodules or plaques
• May be hyperaesthetic.

Nerve lesions:
• Nerves near lesions may be enlarged
• Nerve trunk palsies
• Nerve palsies variable
• Distal symmetrical anaesthesia common.
Lepromin skin test:
Positive -> negative — negative.
ÿ

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DERMATOLOGY - ANSWERS

Acid-fast bacilli:
Rare (paucibacillary) -> some -> lots (multibacillary).
Leprosy is endemic in Asia, Africa, the Pacific Basin and Latin America.
The average incubation period is 5 years. Transmission is probably via
nasal droplets.
Treatment:
It needs to be more intensive in the multibacillary lepromatous type
compared with the tuberculoid type
Dapsone + rifampicin + clofazimine for multibacillary LL
Dapsone + rifampicin for paucibacillary TL.
Complications:
1 Reversal reactions these occur when treatment is initiated in patients
with borderline disease. The disease shifts towards TL, existing lesions
may become inflamed and tender, and new 'satellite' lesions may
occur. Painful nerve trunk palsies may occur.
2 Erythema nodosum leprosum- this occurs in half of patients with LL. It
usually develops within the first few years after treatment is initiated. It
can affect any part of body and is self-limiting. There is associated
fever, malaise, anorexia and anaemia.

Case 14
1 C Withdraw carbamazepine
This is toxic epidermal necrolysis. There is extensive full-thickness
attachment of the epidermis. It is the most severe form of erythema
multiforme. Typically the rash starts as poorly defined macules with
darker centres. There is then sheet-like loss of the epidermis. Mucous
membrane involvement is present in 95% of patients, with involvement
of the oropharynx, eyes, genitalia and anus. I ligh fever is usual.
Most cases are related to an adverse drug reaction. The commonest
culprits are sulphonamides (eg co-lrimoxazole), aromatic
anticonvulsants (eg phenytoin, phenobarbital, carbamazepine), some
NSAIDs (eg phenylbutazone, piroxicam) and allopurinol. The incidence
is increased in patients with HIV infection. There is a high morbidity and
mortality (30%) associated with this condition.
Complications:
• Fluid loss - replace with an extra 3-4 litres per day
• Infection - the main cause of death in these patients
• Impaired thermoregulation
• Increased energy expenditure.

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 DERMATOLOGY ANSWERS

Management:
• Withdraw any suspect drug
• Avoid skin trauma, including large intravascular lines
• Fluid replacement
• Needs ITU/burns unit bed
• Sterile handling of the patient
• Non-adherent skin dressings
• Nasogastric tube and high-protein diet
• Raise environmental temperature to 30 32 "C
• Ophthalmology examination daily.

Case 15
1 8 Rheumatoid arthritis
These pictures show two features nail-fold infarcts and a symmetrical
polyarthropathy with swelling of the MCP joints.
Nail-fold infarcts are seen in association with small-vessel vasculitis.
They are characteristically seen in rheumatoid arthritis, SLE, scleroderma
and dermatomyosilis.
Only 30°/) of patients with rheumatoid arthritis are ANA-positive
(cf SLE, 85%).

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ENDOCRINOLOGY AND METABOI ISM - ANSWERS

Chapter Two Answers

Case 1
1 E Familial dysbetalipoproteinaemia
There is a combined hyperlipidaemia with striate palmar xanthomas.
Palmar xanthomata are almost diagnostic of familial
dysbetalipoproteinaemia, (synonyms are broad-bela disease, remnant
removal disease or type III hyperlipidaemia (Fredrickson/WHO
classification)). Tuberoeruptive xanthomas also occur and may coalesce
to form tuberous xanthomas. Untreated, there is a marked increased
incidence of coronary heart disease and peripheral vascular disease. It is
rare; treatment is with diet, fibrates or statins. In the absence of palmar
xanthomas it cannot be distinguished from familial combined
hyperlipidaemia (type lib) or lipoprotein lipase deficiency (type V or I
hyperlipidaemia) on simple lipid measurement alone. Most (90%) of the
patients are homozygous for apolipoprotein E e2. DNA testing for this is
troublesome because it may identify the presence of e4 which is linked
with early-onset Alzheimer's disease; this information should not be
openly available in the patient's notes without their consent. Plasma can
also be examined by ultracentrifugation for the presence of (S-VLDL
(hence broad-beta), typical of familial dysbetalipoproteinaemia.
About 1% of the population have the e2/e2 phenotype; they have
cholesterol- enriched VI DL and low LDL, but do not have type III
dysbetalipoproteinaemia, whose expression requires the co-existence ot
a further abnormality affecting lipid metabolism. Examples of this are
hypothyroidism and obesity. Note that the total cholesterol is not made
up of LDI and this suggests elevated IDL which is characteristic ol
dysbetalipoproteinaemia. The disorder responds to weight reduction,
fibrates and statins. The high triglycerides confer an elevated risk of
pancreatitis.
Patients with familial mixed hyperlipidaemia have increased VLDL
(triglycerides) and LDL and typically low HDL; they are prone to
coronary artery disease, stroke and peripheral vascular disease.
Treatment is with diet and weight loss, statins, nicotinic acid and fibrates.
The hyperlipidaemia of diabetes most closely resembles this.
Patients with familial hypercholesterolaemia have increased LDL due to
a defect in the LDL receptor inherited in an autosomal dominant manner.
Heterozygosity is present in the UK in ~1 :450 people; their LDL-receptor
activity is reduced by -50%. The commonest presentation, unless picked

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 ENDOCRINOLOGY AND METABOLISM - ANSWERS

up by screening, is early-onset ischaemic heart disease. Tendon and

planar xanthomas occur. It responds to diet, statins, ezetimibe, bile-acid
binding resins, nicotinic acid and fibrates.
Patients with familial hypertriglyceridaemia haveelevaled chylomicrons
and VLDI., with very elevated triglycerides in the serum -stored plasma
has a milky, lipaemic top (due to chylomicrons). Eruptive xanthomas on
the extensor surfaces and lipaemia retinalis occur. Pancreatitis occurs
but an increased risk of ischaemic heart disease is debated.
Pseudohyponatraemia can occur. It responds to a very low fat diet,
fibrates, omega-3 fatty acids and nicotinic acid.

Case 2
1 C Referral to an ophthalmic surgeon
There is a 1 .5-2-cm soft-tissue-density retro-orbital mass arising from
within the right orbit, from either the greater wing of the sphenoid, the
fronto or the zygomatic bones. The orbit itself is proptosed. An
ophthalmic surgeon should be consulted in case the lesion is malignant
or there are compressive problems; benign retro-orbital tumours can
grow very slowly and just be kept under observation. Note that the
medial rectus muscles are of normal size - these are characteristically
involved in Craves' ophthalmopathy.
The thyroid scan shows several signal voids within the gland, suggesting
a multinodular gland. If this is in keeping with the exam findings, then
she could be followed up clinically or with ultrasound. The use of
fine-needle aspiration cytology depends on local practice.
There is little evidence that suppressive doses of thyroxine help suppress
the growth of goitres. Lack of evidence of benefit does not equate to
evidence of no benefit - many thyroidologists therefore still use
suppressive thyroxine. However, there is evidence that patients with a
suppressed TSH have adverse morbidity and mortality.
Case 3
1 C Cranial diabetes insipidus
Considering the problem of polyuria, the following diagnoses need to be
considered:
• Diabetes mellitus
• Diabetes insipidus (Dl):
cranial
nephrogenic
• Primary polydipsia (PP)
• Polyuric phase of renal failure.

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ENDOCRINOLOGY AND METABOLISM ANSWERS

Diabetes mellitus is excluded by the normal fasting glucose, absence of

glucose on urinalysis and lack of weight loss. The + ketones is normal for
a fasting urine. Polyuria is present as the 24-hour urine output is over
2.5 L. There are no clinical features here to distinguish between the
remaining causes, ('lues however could be:
• Psychosis - primary polydipsia
• Evidence of pituitary or hypothalamic disease - cranial Dl.
There is no hypokalaemia or hypercalcaemia, renal failure or evidence
of pituitary or hypothalamic disease. The basal osmolalities show a
moderately concentrated plasma (this mild dehydration, together with a
high sodium and albumin tends to favour Dl; in PP one often sees an
plasma osmolality below 280 mosmol/kg due to a degree of
overhydration) with a low urine osmolality (the latter is unhelpful for
distinguishing between mild Dl and PP). One would imagine from first
principles that in PP the urine would concentrate if the plasma became
concentrated. However, with any cause of chronic polyuria there is a
solute washout from the renal medulla which reduces renal
concentrating ability, hence the low urine osmolality is unhelpful.
A water deprivation test is the usual investigation to do at this stage. Here
the urine osmolality fails to rise appropriately and urine volume remains
high despite the rising plasma osmolality. Once the plasma osmolality
has risen above 295 mosmol/kg, the patient has been adequately water-
deprived and DDAVP is given. Now urine concentrates normally. This is
diagnostic of cranial Dl.
In nephrogenic Dl the urine would fail to concentrate after DDAVP. In
PP one might not see the plasma concentrate to over 295 mosmol/kg,
and the urine to plasma osmolality ratio may remain less than 2.0. If so,
either a prolonged water deprivation lest (Miller and Moses) or AVP
measurement during hypertonic saline infusion could be performed.

Case 4
1 E Primary hyperparathyroidism (PHP)
The baseline biochemistry shows hypercalcaemia, the corrected calcium
is 3.0 mmol/L (albumin is 41 g/L), the phosphate is low and there is a
normal anion gap metabolic acidosis. The 24-hour calcium is elevated,
highly suggestive of PHP. PTH increases serum calcium by mobilising it
from bone and increasing proximal tubular resorption and increases both
phosphate and bicarbonate excretion by preventing their resorption in
the proximal tubule.
The PTI I is not suppressed, suggesting one of three diagnoses:
• Primary hyperparathyroidism (PHP)

160
 ENDOCRINOLOGY AND METABOLISM - ANSWERS

• Terliary hyperparathyroidism (T I II')

• Familial hypercalcaemic hypocalciuria {FH H).
There is no cause for THI' Ihe renal function is normal and vitamin D
deficiency, severe enough to cause TFIP, is unlikely with the normal ALP
(but possible with Ihe early-onset osteoporosis), and malabsorption is not
suggested.
FFHH is not present as the 24-hour urinary calcium is far too high at 9.165
mmol/day. It should not be necessary to calculate the calcium/creatinine
clearance ralio with the 24-hour calcium excretion, bul it is > 0.01,
against the diagnosis of FHH.
urine [Ca2l| x plasma [creatinine] / urine [Ca24] x plasma IcrealinincI
This formula is only valid if both calcium and creatinine are measured on
the same 24-hour urine. PHP lias its highest incidence in the fourth lo
sixth decades when it is twice as common in women; in all other age
groups the incidence is equal. In the UK hospital population, where
routine measurement of serum calcium is common, an incidence of at
least 1% is revealed. Most (99%) have benign tumours (85% adenomas
and 15% multiple abnormal glands) and I % have carcinoma. PI IP can
be part of familial multiple endocrine neoplasia syndromes and this
should be considered if there is a family history of hypercalcaemia or
other endocrine neoplasia or when PHP occurs in the young. The
depression, Colles' fracture at age 5 I and Ihe suggestion of diabetes
insipidus all push one towards definitive management surgical
para Ihyroidectomy.
Ft II I is transmitted in an autosomal dominant fashion and is due (in
most) to a mutation in the calcium-sensing-receptorgene. Consider if
there is a history of unsuccessful neck or parathyroid surgery. It is best
diagnosed by a calcium/creatinine clearance ratio < 0.01 .
In this case the hypertension is a reel herring. One might consider
MEN 2A but there is nothing to suggest a phaeochromocytoma; essential
hypertension is common. If it were MEN 2A, medullary carcinoma of Ihe
thyroid usually (but not exclusively) would have occurred by now.

Case 5
1 B Anterior pituitary function
In the presence of hypoglycaemia there is an inadequate serum Cortisol.
Therefore one can confidently say that hypoadrenalism exists. A short
letracosactrin test will give no more useful information - the patient has
essentially had an insulin tolerance test.
The next question is whether it is primary or secondary hypoadrenalism.

161
ENDOCRINOLOGY AND METABOLISM ANSWERS

Primary adrenal failure would cause mineralocorlicoid and

glucocorticoid deficiency. The clinical information in this scenario does
not point to mineralocorticoid deficiency as the volume status of the
patient is normal, the )VP is 4 cm and there is no postural drop; the
image shows an absence of secondary sexual hair suggesling
hypogonadism; the electrolytes are, at best, not suggestive of
mineralocorticoid deficiency or, at worst, unhelpful. The image does not
show pigmentation which would favour Addison's disease. All this
points to pituitary or hypothalamic disease rather than to primary adrenal
disease - measuring ACTH is mandatory if one suspects Addison's but is
not mandatory here. The stress of a general anaesthetic has precipitated a
crisis. Due to glucocorticoid deficiency he will have inadequate liver
glycogen stores, especially after a fast for a general anaesthetic, hence
severe hypoglycaemia has occurred; one may think the blood pressure is
a little low for the clinical scenario too.
Anterior pituitary function tests should therefore be performed and the
visual fields should be assessed with some urgency in case there is a
lesion compressing the optic chiasm which can go unnoticed.
The possibility of an insulinoma ought to be considered, but the patient
has an alternative cause tor hypoglycaemia and also has urinary ketones.
These indicate a low prevailing burden of insulin in the body during the
fast and suggest that insulin, an insulin-like peptide {eg pro-IGF-II from a
sarcoma) or sulphonylureas are not to blame.

Case 6
1 B Distal renal tubular acidosis - RTA (type I)
The clinical details are of an arrhythmia in a well young lady who has
some aches and pains and a proximal myopathy. The investigations
show a normal anion gap metabolic acidosis with marked
hypokalaemia.
The causes ol a normal anion gap metabolic acidosis include:
• Distal renal tubular acidosis (type 1) - hypokalemic
• Distal renal tubular acidosis (type 4) - hyperkalaemic:
Addison's disease
minera locorticoid res ista nee
hyporeninaemia:
autonomic failure (Shy-Drager)
diabetes mellitus
• Proximal renal tubular acidosis (type 2).
The abdominal X-ray shows nephrocalcinosis, the causes of which are
summarised in the list at the lop of the next page.

162
 ENDOCRINOLOGY AND METABOI ISM - ANSWERS

• Mainly medullary (the usual location —95%):

primary hyperparathyroidism
i- , i i t a
'
) .
60% of cases
distal) n
RTA (type 1)
/»
)i
idiopathic hypercalciuria
hypervitaminosis L)
milk alkali syndrome
primary hyperoxaluria
sarcoidosis
chronic berylliosis
thyrotoxicosis
sulphonamide injury
• Mainly cortical (< 5%):
chronic glomerulonephritis
renal cortical necrosis with recovery ('tram-line' calcification)
• Medullary cystic disease: to some authorities, this is not considered to
be a cause of nephrocalcinosis. It causes calcification at the tips of the
papillae, not in the medulla. There is cystic dilatation of the collecting
ducts with calcification within these.
Hypokalaemia (see p. 160) is responsible for the myopathy and the
arrhythmia. Arrhythmias associated with hypokalaemia include:
• Atrial tachycardia with block
• Atrioventricular dissociation (hence cannon waves in the |VP)
• Ventricular tachycardia or fibrillation.
The ECG shows prominent U waves and small T waves (that can often be
lost within the U wave); this can give the false appearance of a
prolonged QT interval.
Hypokalaemia also reduces gut motility and can cause a frank ileus.
However in ileus there is no pain and bowel sounds are absent, so the
abdominal pain is possibly due to calcium nephrolithiasis.
The only unifying diagnosis is distal RTA (type 1).
The causes of distal RTA (type I) are as follows:
• Autoimmune disease:
Sjogren's syndrome
primary biliary cirrhosis and other autoimmune liver disease
SIE
cryoglobuIinaemia
• Associated with nephrocalcinosis:
primary hyperparathyroidism
vitamin D toxicity
• Tubulointerstitial nephropathy:
chronic pyelonephritis

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ENDOCRINOLOGY AND METABOI ISM - ANSWFRS

chronic obslruclion
renal Iransplantation
• Inherited:
autosomal dominant or, rarely autosomal recessive
sickle cell anaemia
medullary sponge kidney
• Drug-related:
analgesic nephropathy
amphotericin L5.
In this case the other features to note are a mild renal impairment
consistent with volume contraction, which exacerbates the secondary
hyperaldosteronism. There is perhaps a clue to the aetiology in this
youngish lady with a high ALP -primary biliary cirrhosis- or this could
represent the osteomalacia that frequently complicates the acidosis. The
autosomal dominant form can present in adulthood but more normally it
presents in childhood with failure to thrive.
In proximal RTA (type 2) nephrocalcinosis is almost never present; there
are usually multiple defects of tubular function and the urine pH can
become normal with a severe acidosis.

Case 7
1 C MRI pituitary

The history is absolutely classic for pituitary apoplexy. The preceding

headache may allude to the growth of a pituitary tumour, and the fatigue
and weight loss may allude to thyrotrophic and corticotrophic hormone
failure respectively. There is no clue to the stale of the gonadolrophic
hormones because of the combined pill. The diplopia and VI t h nerve
palsy are due to compression within the cavernous sinus on the left; the
cavernous sinuses lie just lateral to the pituitary fossa and through it
travel cranial nerves III, IV, Va, Vb and VI any or all can be affected as
can the optic chiasm. The fields must therefore be checked forthwith as
compression of the chiasm changes the tempo of the case and injects
extreme urgency. If there is any visual loss, then operative
decompression ought to occur within the first week.
There is no evidence to suggest SIADH as the patient is volume-deplete,
tachycardic with a low HP, and becomes dizzy on standing. The
osmolalities are confusing if one has not made the correct assessment of
volume status.
A sensible clinician may send the CSF to virology but it will not give you
the diagnosis. Similarly, Cortisol should be measured as we are
concerned about the pituitary, but ACTH will add nothing. Even Cortisol

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on its own would nol ho the correct answer. Nolo the CSF glucose is
low and if it is 70% of the plasma, then there is a low plasma glucose
too.

Case 8
1 C Langerhans' cell histiocytosis (LCH)
The calculated serum osmolality, (2 x [Na + K] + (glucose + urea) is
304 mosmol/kg, yet the urine is dilute, suggesting a failure of urinary
concentrating ability. The patient is being investigated for diabetes, but
has not lost any weight; one can assume that polyuria and/or polydipsia
raised the possibility of diabetes - the plasma glucose is normal -
therefore diabetes insipidus is almost certainly present.

Specific gravity Osmolality

(mosmol/kg)
1.002 1 00
1.010 285
1 .020 750
1.030 1200
1 .0.35 1 400

There are lucencies on the skull vault, the cause which may be:
• LCH
• Metastases
• Hyperparathyroidism
• Burr hole
• Neurofibroma
• Multiple myeloma
• I'aget's disease
• I Hemangioma
• Infective, eg tuberculosis.
The patient also has a rash, unsuccessfully treated as seborrhoeic
eczema. A rash is the most frequent feature of LCH, but it is often
overlooked. This, together with skull lucencies and diabetes insipidus,
makes Langerhans' cell histiocytosis the only correct answer. A tissue
biopsy should ideally be performed to confirm this. Full anterior pituitary
function tests should be performed. The disease can remit spontaneously
and il it is not causing any trouble, can be observed.
The lucencies were present in childhood, making metastases unlikely;
the patient is too young for myeloma. It is not the pepper-pot skull of

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ENDOCRINOLOGY AND METABOLISM - ANSWERS

hyperparathyroidism. There are no other features in the case to suggest

neurofibromatosis.

Case 9
1 A Primary aldosteronism - bilateral adrenal hyperplasia
There is hypertension and evidence of mineralocorticoid (MC) excess -
an alkalosis with the potassium in the lower part of the normal range. Up
to 40% of patients with surgically confirmed primary aldosteronism have
normal serum potassium; the alkalosis reflects intracellular potassium
depletion.
The next step in the investigation is to look at the plasma renin.
Suppression is compatible with primary aldosteronism; if it is not
suppressed, primary aldosteronism is very unlikely. To increase the
predictive value of this test, it is best performed on a diet with at least
100 mmol sodium per day, though this is a matter of diagnostic finesse
rather than a critical fact for MRCP purposes.
One would normally expect to see that the aldosterone is elevated as the
most likely diagnosis is primary aldosteronism (Conn's syndrome).
Conn's syndrome is an acceptable term for primary aldosteronism
caused by either unilateral adenoma or bilateral adrenal hyperplasia.
Considering mineralocorticoid hypertension more formally, the causes
are as follows:
• Normal MC receptor, normal ligand:
primary aldosteronism
glucocorticoid-remediable hyperaldosteronism (GRA)
• Normal receptor, abnormal ligand:
apparent MC excess (AME):
11 p-hydroxysteroiddehydrogenase (HSD) deficiency
I 1 p-HSD inactivation (glycyrrhetinic acid - liquorice,
carbenoxolone)
deoxycorticosterone (DOC) excess:
adrenal tumour - DOComa
congenital adrenal hyperplasia:
11-hydroxylase deficiency
1 7-hydroxylase deficiency
• Constitutive activation of receptor
progesterone- (P2)- induced hypertension (autosomal dominant
inheritance)
• Increased post-receptor activation:
kiddle's syndrome.
In our case the aldosterone is raised, confirming primary aldosteronism.

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 LNDOCRINOLOGY AND METABOLISM - ANSWERS

The imaging shows normal adrenals, making bilateral adrenal

hyperplasia likely. There is a case to be made for going on to do postural
renin aldosterone studies and possibly a venous catheter for aldosterone.
A therapeutic mistake can be made by performing a unilateral
adrenalectomy on a patient with bilateral disease. Remember that
incidental adrenal masses are common.
Bartter's syndrome does not cause hypertension. In Liddle's syndrome
the aldosterone is low. Phaeochromocytomas are often associated with a
postural drop and the urine catecholamines are typically raised.

Case 10
1 E The statin should be discontinued
One would consider a rise in the transaminases of over three times the
upper limit of normal as a reason to discontinue the statin; otherwise,
they ought not to be discontinued. Increasing evidence shows that statins
are safe to initiate early after myocardial infarction (Ml), and clinical
practice in the UK would be not to stop.
The management of Ml in diabetes (of whatever type) is along standard
lines for non-diabetics. Retinopathy does not preclude thrombolysis.
Patients with diabetes have a worse prognosis after Ml than
non-diabetics but have a greater benefit from thrombolysis and should
always receive thrombolysis (or primary angioplasty) whatever the stage
of retinopathy.1
The absolute benefit of ACE inhibitors post-infarct is clear from several
trials and neither the renal impairment nor proteinuria preclude their
use. The presence of a third heart sound, even in the absence of
pulmonary oedema, is a clear indication of left ventricular dysfunction,
which one would expect in anterior infarction.
Beta-blockers are not contra indicated after Ml in diabetes and they
reduce mortality, sudden cardiac death and re-infarction after Ml. The
loss of hypoglycaemic awareness is inconsequential. Intravenous
p-blockade is more difficult, the evidence is contradictory but, on
balance, they are probably beneficial, although the effect may be smaller
than previously thought.2 In the presence of hypertension that precludes
thrombolysis, [S-blockers will lower the BP and allow thrombolysis to be
given. The matter in this question is easier as the systolic pressure
precludes intravenous |:i-blockade.

' Aiollo IP, Cahill MT, Wong |S. 2001.Systemic considerations in the management of
diabetic: retinopathy. American Journal of Ophthalmology, 132, 760 776.
2
Borrello F, Beahan M, Klein L, Gheorghiade M. 2003. Reappraisal of beta-blocker
therapy in the acute and chronic post-myocardial infarction period. Review of
Cardiovascular Medicine, 4(suppl 3): SI 3-S24.

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ENDOCRINOLOGY AND METABOLISM ANSWERS

Case 11
1 C Chronic pancreatitis
The image shows pancreatic calcification across the abdomen at the
level of the first lumbar vertebra, which is almost diagnostic of chronic
pancreatitis. Intermittent, boring pain through to the back is
characteristic and the suggestion (hat he stopped drinking because of
abdominal pain is evidence of the aetiology. There is a mild anaemia
and a faint macrocytosis this could be due to Bi> deficiency, which is
occasionally found in chronic pancreatitis. The capillary glucose is
7.9 mmol/L and although we do not know whether the patient had eaten
recently, this must make one think of either diabetes mellitus or impaired
glucose tolerance - the appropriate diagnostic samples must be taken. A
mild obstructive jaundice is a frequent finding; malabsorption of fat-
soluble vitamins is common, but clinical manifestations such as
osteomalacia are rare.
Carcinoma of the head of the pancreas is a possibility but the pain is
more relentless, weight loss more of a feature, and the jaundice occurs
earlier in carcinoma; pancreatic calcification is less of a feature - but
chronic pancreatitis can develop in the pancreas proximal to an
obstructing carcinoma. Pancreatic carcinoma has a mean age of onset of
55 years, and the duration of symptoms is less than 6 months in half of
patients; the average duration of symptoms before death is between 4
and 10 months.
There is nothing to suggest metastases or tuberculous adrenal disease.

Case 12
1 D McArdle's disease
This patient's history goes back to childhood and he is now an
underweight adult with proximal wasting and normal reflexes
(MRCP-speakfor a myopathy).
The causes of myopathy are:
• Endocrine:
hypocalcaemia
hypokalemia
hypomagnesaemia
hypo- or hyperthyroidism
Cushing's syndrome
glycogen storage disorders
lipid storage diseases
mitochondrial diseases

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 ENDOCRINOLOGY AND METABOLISM ANSWERS

periodic paralyses
• Inflammalory:
polymyositis
dermatomyositis
• Toxic:
corticosteroids
statins
colchicine
amiodarone
alcohol
penicillamine
halolhane- malignant hyperpyrexia
vincristine
chloroquine.
There is blood in the dipstick urinalysis but no cells or casts are seen on
microscopy, suggesting myoglobinuria. This occurs in muscle injury or
damage, as in:
• Trauma/compression
• Exercise
• Burns and electric shocks
• Viral myositis
• Sepsis - gas gangrene, tetanus, Legionnaires', shigellosis
• Malignant hyperpyrexia
• Coma
• Seizures
• Metabolic myopathies:
hypokalemia
glycogen storage disorders
mitochondrial diseases
lipid storage disorders
defects of carbohydrate metabolism
• Drugs/toxins - AZT, slat ins, ethylene glycol, isopropyl alcohol,
phencyclidine
• Snake bites.
The metabolic myopathies present with exercise intolerance and cramps
and myoglobinuria. Cramps and muscle discomfort may occur after brief
exercise (as in this case) or prolonged activity. Glycogen is the main
source of energy during brief exercise, while fatly acids are more
important in prolonged exercise. These cramps occurring early favour
glycogen storage disease.
There are several glycogen storage diseases. Pompe's usually presents in
children but can rarely present in an adult with a limb-girdle dystrophic

1 69
ENDOCRINOLOGY AND METABOLISM - ANSWERS

picture. McArdle's (due to muscle phosphorvlase deficiency), presenting

with exertional cramps early during exercise, is associated with
elevations of LDH, creatine kinase and myoglobinuria. Patients have a
normal lifespan and there is no association with hepatomegaly.
There is no hypolhalamo-pituitary-adrenal axis pathology (the Cortisol of
1 70 nmol/L does not have a sampling time).

Case 13
1 C Impaired glucose tolerance
This question requires a practical knowledge of the diagnostic criteria for
normality, impaired fasting glucose (IPG), impaired glucose tolerance
(IGF), and diabetes mellitus (DM). While these are complex, they must
be simplified to be practically useful. They are important as we are
habitually faced with interpretingglucose levels.
One must identify normality and identify when normality is not present.
Furthermore one must identify who to investigate more intensively (or
suggest that the GP investigates further) with surveillance, repeat testing
or, rarely, an oral glucose tolerance test (OGTT).
The importance of diagnosing diabetes mellitus is apparent. However,
the importance of diagnosing both impaired fasting glucose and
impaired glucose tolerance is often overlooked. IPG and IGT identify
patients who are at increased risk of developing diabetes; some 5% per
year, or 30% at 1 0 years. They also identify patients who are at increased
risk of developing macrovascular disease. Prospective data is sparse but
it seems that the risk of progression to DM and macrovascular disease is
greater with IGT than with IFG. Their other macrovascular risk factors
must be addressed.
There is no substitute for looking at the full WHO guidelines on the
diagnosis of diabetes but they are cumbersome.' The following points
must be taken with the proviso that samples must be repeated in
asymptomatic individuals; hyperglycaemia must be interpreted with
extreme caution in those with acute infective, traumatic, circulatory or
other stress as it may be transitory.
It is helpful to remember that, broadly speaking:
On fasting venous plasma samples:
ÿ6.0 mmol/L suggests normality;
>7.0 mmol/L suggests diabetes;
in-between is IFG.
After a 75 g glucose load:
>11.1 mmol/L suggests diabetes;

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 ENDOCRINOLOGY AND METABOLISM - ANSWERS

< 7.8 suggests normality;

in-between is IGT.
A random value of:
5.5 mmol/L strongly suggests normality;
ÿ 11.1 mmol/L suggests DM.

1
http://www.diataes.org.uk/infocentre/carerec/newdiagnotK.htm

Case 14
1 D Hydrocortisone 100 mg intravenously stat and 20 mg orally tds
The clinical scenario is hyponatraemia. There is a major clue to a
possible aetiology in that she takes inhalers for mild COPD, possibly
suggesting steroids.
The first part of establishing the aetiology is establishing the volume
status of the patient. The following table outlines the possible causes
based on the volume.

Hypovolaemic Euvolaemic Hypervolemic

Diuretics SIADH Heart failure
Type 4 RTA: Glucocorticoid deficiency Renal:
• Diabetes mellitus • Acute and chronic renal
Hypothyroidism
• Mineralocorticoid failure
deficiency, eg Addison's Sick cell concept • Nephrotic syndrome
disease or isolated Inappropriate intravenous Liver cirrhosis
aldosterone deficiency fluids, eg dextrose
• Mineralocorticoid Inappropriate intravenous
resistance, eg fluids
spironolactone
Salt-wasting nephropathy:
• Post-obstruction
• Tubulointerstitial
nephropathy
• Pyelonephritis
Cerebral salt wasting
Severe osmotic diuresis
Other loss
• Gut eg vomiting, diarrhoea
• Excess sweating
• Burns

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