Case 9 Questions 1-10

Enjoy working thorugh the following questions. We hope they aid your learning. If you have any issues or feedback, please email [email protected].

---

Question 1

A 35-year-old woman attends A&E because of a 3-month history of headache, palpitations, diarrhoea, and weight loss. She takes no medications. Her pulse is 110/min and blood pressure is 125/70mmHg. Examination shows warm, moist skin and diffuse hyperreflexia. An MRI of the brain shows a pituitary mass. The underlying cause of this patient’s condition is best explained by binding of a ligand to which of the following?

1. Intracytosolic nuclear receptor
2. Receptor tyrosine kinase
3. G Protein-coupled receptor
4. Membrane bound guanylate cyclase
5. Non-receptor tyrosine kinase

Question 2

A 29-year-old woman attends GP because of intermittent episodes of sharp chest pain and palpitations. She appears nervous. Her pulse is 115/min and irregularly irregular, and blood pressure is 139/86mmHg. Examination shows a fine tremor on both hands and digital swelling; the extremities are warm. There is retraction of the right upper eyelid. Which of the following is the most appropriate next step in the management of this patient?

1. Amiodarone
2. Propylthiouracil
3. Warfarin
4. Asprin
5. Propranolol

Question 3

A 37-year-old woman goes to A&E because of a 2-week history of palpitations and loose stools. She has had a 2.3kg weight loss over the past month. She has had no change in appetite. She has no history of serious illness. She takes no medications. She appears pale. Her temperature is 37.8C, pulse is 110/min, respirations are 20/min, and blood pressure is 126/78mmHg. The abdomen is soft and non-tender. There is a bilateral hand tremor with outstretched arms and a palpable thyroid nodule in the left lobe. Serum laboratory studies shows a TSH level of 0.03uU/mL and thyroxine level of 28ug/dL. A radioactive iodine uptake scan shows enhancement in a 3-cm encapsulated nodule in the lower left lobe with decreased uptake in the remaining gland. Which of the following is the most likely diagnosis?

1. Thyroid storm
2. Hashimotos thyroiditis
3. Graves’ disease
4. Toxic adenoma
5. Goitre

Question 4

You are a junior doctor on a rotation in General Practice. A 35-year-old male presents because he feels tired all the time. Upon further questioning, he stated that his mood was low and was struggling to concentrate at work. For the last 3 weeks, he has been waking up at 3 am every morning and not been able to get back to sleep. He has lost 3kg in weight because his appetite is so poor. He confides that he has had fleeting thoughts of ending his life but has not made any plans and states he could never do that to his children. He denies any previous periods of elation or hyperactivity. He denies any thought disorder or perceptual abnormalities. There is no previous psychiatric history. What is the most appropriate drug to commence this patient on?

1. Amitryptyline
2. Mirtazapine
3. Venlaxfaxine
4. Lithium
5. Sertraline

Question 5

A 36-year-old woman attends GP because of an 8-month history of occasional tremor. The tremor is accompanied by sudden restlessness and nausea, which disrupts her daily work as a professional violinist. The symptoms worsen shortly before upcoming concerts but also appear when she goes for a walk in the city. She is concerned that she might have a neurological illness and have to give up her career. The patient experiences difficulty falling asleep because she cannot stop worrying that a burglar might break into her house. Her appetite is good. She drinks one glass of wine before performances “to calm her nerves” and otherwise drinks 2-3 glasses of wine per week. The patient takes daily multivitamins as prescribed. She appears nervous. Her temperature is 36.8C, pulse is 92/min, and blood pressure is 130/80mmHg. On examination, a fine tremor on both hands is noted. She exhibits muscle tension. The remainder of the neurological exam shows no abnormalities. Which of the following is the most likely explanation for this patient’s symptoms?

1. Generalised anxiety disorder
2. Panic disorder
3. Essential tremour
4. Social phobia
5. Alcohol-dependance disorder

Question 6

A 58-year-old man attends GP because of depressed mood for 6 months. He works as a store manager and cannot concentrate at work anymore. He experiences daytime sleepiness and fatigue because he repeatedly wakes up at night and has difficulties falling asleep again after 4am. He reports no longer taking pleasure in activities he used to enjoy, such as going fishing with his son. He has decreased appetite and has had a weight-loss of 5kg over the past 6 months. He does not have suicidal ideation. He has no history of serious illness and takes no medication. He is divorced and lives with his girlfriend. He drinks several alcoholic beverages on the weekend. He does not take any medications. He is diagnosed with major depressive disorder and a trial of sertraline is suggested. The patient is at greatest risk for which of the following adverse effects?

1. Postural hypotension
2. Serotonin syndrome
3. Delayed ejaculation
4. Increased suicidality
5. Urinary retention

Question 7

Which of these is not a function of the thyroid hormones? ​

1. Increased basal metabolic rate
2. Increased glyconeogenesis
3. Increased protein synthesis
4. Increased lipogenesis
5. Thermogenesis

Question 8

A patient has come to the GP to receive the results of their recent blood tests. The investigations confirmed a diagnosis hypothyroidism. The GP wants to start the patient on treatment with levothyroxine. Which of these is not a known side effect of levothyroxine ?

1. Palpitations
2. Agranulocytosis
3. Flushing
4. Weight loss
5. Headache

Question 9

Which of the following does not appear on the DSM 5 criteria for depression?

1. Depressed mood
2. Feeling of hopelessness
3. Psychomotor changes
4. Feeling of worthlessness or inappropriate guilt
5. Fatigue or loss of energy

Question 10

Which of these is first line drug treatment of generalized anxiety disorder?

1. CBT
2. Sertraline
3. Self-help interventions
4. Pregabalin
5. Diazepam