Endocrinology & Diabetes — MCQs
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A 32-year-old woman presents with palpitations and anxiety. Examination reveals a fine tremor, warm moist skin, and a smooth, non-tender goitre. Thyroid function tests show TSH <0.05 mU/L (0.5-5.0), free T4 32 pmol/L (9-25), free T3 12.4 pmol/L (3.5-6.5). TSH receptor antibodies are positive. She is planning pregnancy in the next 6 months. What is the most appropriate initial management?
A 69-year-old man with type 2 diabetes presents to the emergency department with confusion. His wife reports he has had diarrhoea and vomiting for 4 days. On examination, he is drowsy but rousable, blood pressure 95/60 mmHg, heart rate 105 bpm. Capillary glucose is 42.8 mmol/L. Blood tests show sodium 152 mmol/L, urea 18.4 mmol/L, creatinine 185 µmol/L, serum osmolality 348 mOsm/kg. Venous blood gas shows pH 7.36, ketones 0.4 mmol/L. What is the diagnosis?
What is the recommended frequency for diabetic retinopathy screening in adults with type 1 or type 2 diabetes who have no evidence of retinopathy?
A 48-year-old woman presents with a 6-month history of constipation, dry skin, weight gain of 8kg, and fatigue. Blood tests show TSH 42.1 mU/L (0.5-5.0), free T4 6.2 pmol/L (9-25), and positive thyroid peroxidase antibodies. What is the most appropriate initial levothyroxine dose for this patient?
A 23-year-old woman with type 1 diabetes for 9 years presents to the emergency department with vomiting and abdominal pain. Capillary glucose is 24.6 mmol/L, ketones 4.2 mmol/L. Venous blood gas shows pH 7.18, bicarbonate 11 mmol/L, potassium 5.8 mmol/L. What is the correct initial fluid and potassium replacement strategy?
A 55-year-old woman with type 2 diabetes for 6 years presents for review. Her HbA1c is 64 mmol/mol despite maximal doses of metformin and a DPP-4 inhibitor. She has a BMI of 33 kg/m². She works as a lorry driver. eGFR is 68 ml/min/1.73m². Which is the most appropriate next step in her diabetes management?
A 64-year-old man with type 2 diabetes treated with metformin and gliclazide presents with a 4-month history of redness and swelling of his right foot. Examination reveals a warm, erythematous, swollen right foot with intact skin but a rocker-bottom deformity. Foot pulses are palpable. X-ray shows bone and joint destruction. What is the most likely diagnosis?
A 17-year-old girl presents to the emergency department with a 3-week history of polyuria, polydipsia, and 6kg weight loss. She appears thin and mildly dehydrated. Blood glucose is 18.2 mmol/L. Urinalysis shows glucose 3+ and ketones 1+. Venous blood gas shows pH 7.38, bicarbonate 22 mmol/L. What is the most appropriate initial management?
A 26-year-old woman with type 1 diabetes is 16 weeks pregnant. Her pre-pregnancy HbA1c was 51 mmol/mol. She monitors blood glucose closely with targets of 5.3 mmol/L fasting and <7.8 mmol/L 1-hour post-prandial. Despite good compliance, she has experienced three episodes of severe hypoglycaemia requiring assistance in the past 4 weeks. Her current insulin regimen is insulin detemir 18 units morning and 14 units evening, with insulin aspart before meals. What change in her management approach is most appropriate?
A 33-year-old woman with Graves' disease has been taking carbimazole 20mg once daily for 6 months. She now presents with a 2-day history of sore throat, fever, and general malaise. Examination shows temperature 38.4°C, pulse 92 bpm, and pharyngeal erythema. What is the most appropriate immediate management?
Endocrinology & Diabetes UK Medical PG Practice Questions and MCQs
Question 81: A 32-year-old woman presents with palpitations and anxiety. Examination reveals a fine tremor, warm moist skin, and a smooth, non-tender goitre. Thyroid function tests show TSH <0.05 mU/L (0.5-5.0), free T4 32 pmol/L (9-25), free T3 12.4 pmol/L (3.5-6.5). TSH receptor antibodies are positive. She is planning pregnancy in the next 6 months. What is the most appropriate initial management?
- A. Carbimazole titration regime
- B. Propylthiouracil (Correct Answer)
- C. Carbimazole block and replace regime
- D. Radioiodine therapy
- E. Propranolol alone
Explanation: ***Propylthiouracil*** - **Propylthiouracil (PTU)** is the initial treatment of choice for hyperthyroidism in women who are **planning pregnancy** or are in the **first trimester**, due to a lower risk of **teratogenesis** compared to Carbimazole. - It is preferred to avoid potential Carbimazole-induced **congenital malformations** such as aplasia cutis or choanal atresia, which are linked to its use in early pregnancy. *Carbimazole titration regime* - Although a standard first-line therapy for **Graves' disease** in non-pregnant individuals, this regime is generally avoided in patients **planning pregnancy** due to its known **teratogenic potential**. - Use in early pregnancy is associated with specific defects like **aplasia cutis**, often necessitating a switch to PTU if conception occurs. *Carbimazole block and replace regime* - This regime uses high-dose antithyroid drugs to block thyroid hormone production combined with **Levothyroxine** supplementation. - The inclusion of **Levothyroxine** makes this regime unsuitable for pregnancy, as it complicates accurate assessment of fetal and maternal thyroid function and may lead to poor **fetal thyroid control**. *Radioiodine therapy* - **Radioiodine therapy** is definitively contraindicated during **pregnancy** and requires patients to delay conception for at least **6 months** post-treatment. - Given the patient's plan to conceive within the next 6 months, this option is inappropriate due to the necessary waiting period and absolute contraindication. *Propranolol alone* - **Propranolol** is effective for symptomatic control of **hyperthyroidism**, alleviating symptoms like **palpitations**, anxiety, and tremor. - However, it does not treat the underlying **thyrotoxicosis** by reducing thyroid hormone synthesis and therefore cannot be used as monotherapy for Graves' disease.
Question 82: A 69-year-old man with type 2 diabetes presents to the emergency department with confusion. His wife reports he has had diarrhoea and vomiting for 4 days. On examination, he is drowsy but rousable, blood pressure 95/60 mmHg, heart rate 105 bpm. Capillary glucose is 42.8 mmol/L. Blood tests show sodium 152 mmol/L, urea 18.4 mmol/L, creatinine 185 µmol/L, serum osmolality 348 mOsm/kg. Venous blood gas shows pH 7.36, ketones 0.4 mmol/L. What is the diagnosis?
- A. Diabetic ketoacidosis
- B. Hyperosmolar hyperglycaemic state (Correct Answer)
- C. Euglycaemic diabetic ketoacidosis
- D. Acute kidney injury with hyperglycaemia
- E. Mixed DKA and HHS
Explanation: ***Hyperosmolar hyperglycaemic state*** - This diagnosis is confirmed by the combination of extreme **hyperglycaemia** (42.8 mmol/L), severe **hyperosmolality** (348 mOsm/kg), and the absence of significant **ketonemia** (0.4 mmol/L) or **acidosis** (pH 7.36). - It typically presents in elderly **type 2 diabetics** with a long history of symptoms (4 days of diarrhoea and vomiting) leading to profound **dehydration** as evidenced by hypotension and acute kidney injury. *Diabetic ketoacidosis* - Characterized by the triad of hyperglycemia, significant **ketonemia** (>3.0 mmol/L), and **metabolic acidosis** (pH <7.3), which are absent here (ketones 0.4 mmol/L, pH 7.36). - Typically presents more acutely in **type 1 diabetes** and includes symptoms like abdominal pain and Kussmaul respirations, which are not described. *Euglycaemic diabetic ketoacidosis* - Defined by the presence of **ketoacidosis** (acidosis and ketonemia) despite having **normal or only mildly elevated blood glucose** (<11 mmol/L). - This patient’s glucose levels are extremely high (42.8 mmol/L), and his **blood pH** is within the normal range, ruling out this condition. *Acute kidney injury with hyperglycaemia* - While the patient does have **acute kidney injury** (elevated urea and creatinine) and **hyperglycaemia**, these are components of the broader syndrome of HHS. - This option fails to capture the defining characteristic of severe **hyperosmolality** and the overall clinical picture of a diabetic emergency. *Mixed DKA and HHS* - This diagnosis requires meeting the diagnostic criteria for both DKA and HHS, specifically significant **ketosis** and **metabolic acidosis** occurring alongside extreme hyperosmolality. - Since the **pH is 7.36** (normal) and **ketones are 0.4 mmol/L** (below diagnostic thresholds), the criteria for the DKA component are not met.
Question 83: What is the recommended frequency for diabetic retinopathy screening in adults with type 1 or type 2 diabetes who have no evidence of retinopathy?
- A. Every 6 months
- B. Annually (Correct Answer)
- C. Every 2 years
- D. Every 3 years
- E. Every 5 years
Explanation: ***Annually***- For adults with **Type 1** or **Type 2 diabetes** who show no signs of retinopathy, the standard clinical recommendation is an **annual retinal screening** to detect early microvascular changes.- **Annual screening** is crucial because diabetic retinopathy is a major cause of **preventable blindness**, and regular checks allow for timely intervention if damage begins.*Every 6 months*- **Six-month intervals** are typically reserved for patients who already have **pre-existing retinopathy** or for monitoring during **pregnancy**.- Using this frequency for patients with no evidence of disease would lead to unnecessary clinical burden without significant diagnostic gain.*Every 2 years*- While some health systems consider **biennial screening** for patients with consistently stable **glycemic control**, the current standard of care for most guidelines remains annual.- Extending the interval to **2 years** may miss rapid progression if a patient's metabolic state happens to deteriorate suddenly.*Every 3 years*- A **3-year interval** is too long and increases the risk of **proliferative retinopathy** or **macular edema** developing unnoticed between exams.- Most international specialist bodies, such as the **ADA** and **NHS**, do not support a three-year gap for initial screening phases.*Every 5 years*- Screening **every 5 years** is inadequate for the management of chronic diabetes because **microvascular complications** can progress significantly within this timeframe.- Routine eye exams for diabetics require much more frequent monitoring than the general population due to the specific risks of **hyperglycemia-induced retinal damage**.
Question 84: A 48-year-old woman presents with a 6-month history of constipation, dry skin, weight gain of 8kg, and fatigue. Blood tests show TSH 42.1 mU/L (0.5-5.0), free T4 6.2 pmol/L (9-25), and positive thyroid peroxidase antibodies. What is the most appropriate initial levothyroxine dose for this patient?
- A. 100 micrograms once daily
- B. 50 micrograms once daily with dose increase every 3-4 weeks (Correct Answer)
- C. 25 micrograms once daily with dose increase every 4 weeks
- D. 75 micrograms once daily
- E. 150 micrograms loading dose then 100 micrograms daily
Explanation: ***50 micrograms once daily with dose increase every 3-4 weeks***- For adults under 65 without **cardiac disease**, an initial **Levothyroxine** dose of 50 mcg is appropriate to begin treatment and minimize adverse effects.- The dose should be **titrated** every 3-4 weeks based on **TSH levels** until the patient's TSH is within the target therapeutic range.*100 micrograms once daily*- Starting with a full replacement dose like **100 micrograms** might induce **iatrogenic hyperthyroidism** or cardiac strain in some patients, even without known cardiac disease.- This option does not mention the critical step of **gradual dose titration** and monitoring, which is essential for safe and effective management of hypothyroidism.*25 micrograms once daily with dose increase every 4 weeks*- A starting dose of **25 micrograms** is typically reserved for **elderly patients** or those with **pre-existing ischaemic heart disease** to prevent cardiac complications.- For a 48-year-old woman without known cardiac risk factors, this dose would be **sub-therapeutic** and delay achieving optimal thyroid function.*75 micrograms once daily*- **75 micrograms** is not a commonly recommended standard **initial starting dose** in clinical guidelines, which typically suggest 25, 50, or 100 mcg increments.- Like other single-dose options, it fails to include the essential component of **biochemical monitoring** and subsequent dose adjustments, which are crucial for effective treatment.*150 micrograms loading dose then 100 micrograms daily*- **Loading doses** of levothyroxine are specifically indicated only for life-threatening conditions like **Myxoedema Coma**, which is not the case for this patient.- Administering such a high initial dose to a stable patient with hypothyroidism could precipitate dangerous **thyrotoxic symptoms** or cardiac events.
Question 85: A 23-year-old woman with type 1 diabetes for 9 years presents to the emergency department with vomiting and abdominal pain. Capillary glucose is 24.6 mmol/L, ketones 4.2 mmol/L. Venous blood gas shows pH 7.18, bicarbonate 11 mmol/L, potassium 5.8 mmol/L. What is the correct initial fluid and potassium replacement strategy?
- A. 0.9% sodium chloride without potassium chloride at 1000 ml/hour initially (Correct Answer)
- B. 0.9% sodium chloride with 40 mmol/L potassium chloride at 500 ml/hour
- C. 0.45% sodium chloride with 40 mmol/L potassium chloride at 500 ml/hour
- D. Hartmann's solution without potassium at 500 ml/hour
- E. 0.9% sodium chloride with 20 mmol/L potassium chloride at 1000 ml/hour
Explanation: ***0.9% sodium chloride without potassium chloride at 1000 ml/hour initially***- In **diabetic ketoacidosis (DKA)**, initial fluid resuscitation prioritizes **volume expansion** to restore perfusion and reduce counter-regulatory hormones, with **0.9% sodium chloride** given rapidly (1000 ml/hour for the first hour).- Given the patient's **hyperkalemia (K+ 5.8 mmol/L)**, adding potassium chloride to the initial fluid is contraindicated to prevent worsening **hyperkalemia**, which can lead to life-threatening arrhythmias.*0.9% sodium chloride with 40 mmol/L potassium chloride at 500 ml/hour*- Administering potassium with a serum level of **5.8 mmol/L** is dangerous and can precipitate severe **hyperkalemia**, especially before insulin has begun to shift potassium intracellularly.- An initial infusion rate of **500 ml/hour** is generally insufficient for the rapid volume repletion required in the first hour of DKA management.*0.45% sodium chloride with 40 mmol/L potassium chloride at 500 ml/hour*- **Hypotonic saline (0.45% NaCl)** is not recommended for initial DKA resuscitation as it is less effective for rapid volume expansion and carries a higher risk of **cerebral edema** due to rapid decreases in plasma osmolality.- Similar to the above, adding **potassium** when the patient is already hyperkalemic is inappropriate and risky.*Hartmann's solution without potassium at 500 ml/hour*- While balanced crystalloids like Hartmann's solution can be used, **0.9% sodium chloride** is the more commonly recommended and studied initial fluid for DKA, especially in patients who may have significant hyponatremia.- The infusion rate of **500 ml/hour** is too slow for the crucial initial fluid bolus needed to correct severe dehydration in DKA.*0.9% sodium chloride with 20 mmol/L potassium chloride at 1000 ml/hour*- Even a lower concentration of **potassium chloride (20 mmol/L)** should be withheld in the initial fluid given the patient's presenting **hyperkalemia (K+ 5.8 mmol/L)**.- Potassium replacement should only be initiated once serum potassium levels normalize or fall below 5.0-5.5 mmol/L, typically after insulin administration has begun.
Question 86: A 55-year-old woman with type 2 diabetes for 6 years presents for review. Her HbA1c is 64 mmol/mol despite maximal doses of metformin and a DPP-4 inhibitor. She has a BMI of 33 kg/m². She works as a lorry driver. eGFR is 68 ml/min/1.73m². Which is the most appropriate next step in her diabetes management?
- A. Add an SGLT-2 inhibitor (Correct Answer)
- B. Add pioglitazone
- C. Add a GLP-1 receptor agonist
- D. Add a sulphonylurea
- E. Switch to basal-bolus insulin regimen
Explanation: ***Add an SGLT-2 inhibitor*** - **SGLT-2 inhibitors** are a preferred addition to triple therapy as they promote **weight loss** and have a very low risk of **hypoglycemia**, which is crucial for a **lorry driver** (Group 2 license). - The patient's **eGFR of 68 ml/min** is well within the acceptable range (typically >45 ml/min) for initiating this class of medication, which also offers **cardio-renal protective benefits**. *Add pioglitazone* - While effective for glycemic control, **pioglitazone** is associated with **weight gain** and fluid retention, which is undesirable given the patient's existing **obesity** (BMI 33). - It lacks the specific cardiovascular and renal benefits compared to SGLT-2 inhibitors, which are often prioritized in current guidelines. *Add a GLP-1 receptor agonist* - NICE guidelines typically suggest **GLP-1 receptor agonists** only if the **BMI is ≥35 kg/m²** or if insulin would have significant occupational implications due to weight. The patient's BMI is 33 kg/m². - Although she is a lorry driver, an **SGLT-2 inhibitor** is generally a more appropriate first choice in triple therapy intensification given her BMI and eGFR, due to its low hypoglycemia risk and weight loss benefits. *Add a sulphonylurea* - **Sulphonylureas** carry a significant risk of **hypoglycemia**, which poses a major safety risk and legal complication for a **lorry driver** under **DVLA regulations**. - This class often leads to **weight gain**, further complicating the management of her high BMI. *Switch to basal-bolus insulin regimen* - Transitioning to **insulin therapy** is premature as the patient has not yet exhausted appropriate **triple oral therapy** options and still has adequate renal function. - Insulin use requires strict **DVLA notification** and monitoring for commercial drivers due to the high risk of severe **hypoglycemic episodes**.
Question 87: A 64-year-old man with type 2 diabetes treated with metformin and gliclazide presents with a 4-month history of redness and swelling of his right foot. Examination reveals a warm, erythematous, swollen right foot with intact skin but a rocker-bottom deformity. Foot pulses are palpable. X-ray shows bone and joint destruction. What is the most likely diagnosis?
- A. Diabetic foot osteomyelitis
- B. Acute gout
- C. Charcot neuroarthropathy (Correct Answer)
- D. Septic arthritis
- E. Cellulitis with deep vein thrombosis
Explanation: ***Charcot neuroarthropathy*** - The combination of **type 2 diabetes**, a warm, swollen foot with **intact skin**, and a classic **rocker-bottom deformity** is pathognomonic for Charcot foot. - **Palpable pulses** and extensive **bone and joint destruction** on X-ray in the absence of an ulcer help differentiate this from infectious or ischemic processes. *Diabetic foot osteomyelitis* - Usually occurs secondary to a **chronic skin ulcer** which acts as a portal for infection, whereas this patient has **intact skin**. - While X-rays show bone destruction, the clinical presentation of a **midfoot collapse** over 4 months without systemic illness favors a neuropathic over an infectious etiology. *Acute gout* - Typically presents as an **acute, exquisitely painful** episode localized to a single joint, most commonly the **first metatarsophalangeal joint**. - It does not cause the characteristic **rocker-bottom deformity** or the chronic, progressive bone destruction seen in this patient's midfoot. *Septic arthritis* - Presents with **acute onset** of severe pain, fever, and systemic toxicity, which are inconsistent with a **4-month history**. - Joint aspiration would typically reveal a **high white cell count** and organisms, rather than the structural architectural collapse seen here. *Cellulitis with deep vein thrombosis* - **Cellulitis** causes localized redness and warmth but would not result in **radiographic bone destruction** or structural foot deformity. - **Deep vein thrombosis** presents with calf swelling and pain but does not explain the **chronic joint destruction** and palpable foot pulses documented.
Question 88: A 17-year-old girl presents to the emergency department with a 3-week history of polyuria, polydipsia, and 6kg weight loss. She appears thin and mildly dehydrated. Blood glucose is 18.2 mmol/L. Urinalysis shows glucose 3+ and ketones 1+. Venous blood gas shows pH 7.38, bicarbonate 22 mmol/L. What is the most appropriate initial management?
- A. Start basal-bolus subcutaneous insulin regimen and provide diabetes education (Correct Answer)
- B. Give stat dose of intramuscular insulin and reassess in 2 hours
- C. Commence oral metformin 500mg twice daily
- D. Admit for observation and repeat blood tests in 6 hours
- E. Start variable rate intravenous insulin infusion immediately
Explanation: ***Start basal-bolus subcutaneous insulin regimen and provide diabetes education*** - The patient presents with classic symptoms of **Type 1 Diabetes Mellitus** (weight loss, polyuria, polydipsia) but does not meet the criteria for **Diabetic Ketoacidosis (DKA)** as the pH and bicarbonate are within normal limits. - In the absence of DKA, the gold standard for management is starting a **basal-bolus subcutaneous insulin** regimen and initiating **structured education** and specialist team follow-up. *Give stat dose of intramuscular insulin and reassess in 2 hours* - **Intramuscular insulin** is not a standard route for the chronic management or stabilization of new-onset Type 1 diabetes and lacks a **sustained effect**. - Relying on a single stat dose without a long-term **basal-bolus plan** fails to address the underlying total insulin deficiency and risks glycemic rebound. *Commence oral metformin 500mg twice daily* - This patient likely has **Type 1 Diabetes**, characterized by absolute insulin deficiency, which requires **replacement insulin**, not oral biguanides. - **Metformin** is the first-line treatment for Type 2 diabetes and would be ineffective and potentially dangerous as monotherapy in this clinical scenario. *Admit for observation and repeat blood tests in 6 hours* - Delaying treatment in a patient with **significant hyperglycemia** and ketonuria increases the risk of progression to **life-threatening DKA**. - While observation is necessary, it must be accompanied by the active initiation of **insulin therapy** and fluid rehydration if indicated. *Start variable rate intravenous insulin infusion immediately* - **Variable rate intravenous insulin (VRIII)** is indicated for patients with **DKA**, surgical patients, or those unable to eat; it is not required for stable patients with normal pH and bicarbonate. - Using intravenous insulin in a stable patient is unnecessarily invasive and complicates the transition to a **long-term subcutaneous regimen**.
Question 89: A 26-year-old woman with type 1 diabetes is 16 weeks pregnant. Her pre-pregnancy HbA1c was 51 mmol/mol. She monitors blood glucose closely with targets of 5.3 mmol/L fasting and <7.8 mmol/L 1-hour post-prandial. Despite good compliance, she has experienced three episodes of severe hypoglycaemia requiring assistance in the past 4 weeks. Her current insulin regimen is insulin detemir 18 units morning and 14 units evening, with insulin aspart before meals. What change in her management approach is most appropriate?
- A. Reduce basal insulin doses by 10-20% and accept slightly higher fasting glucose readings to prevent hypoglycaemia
- B. Switch to continuous subcutaneous insulin infusion (pump therapy) to reduce hypoglycaemia risk
- C. Continue current regimen as hypoglycaemia is expected in first and second trimester with tight control
- D. Relax glucose targets to fasting <6.0 mmol/L and 1-hour post-prandial <8.5 mmol/L to reduce hypoglycaemia frequency (Correct Answer)
- E. Add continuous glucose monitoring with hypoglycaemia alerts but maintain current targets and insulin doses
Explanation: ***Relax glucose targets to fasting <6.0 mmol/L and 1-hour post-prandial <8.5 mmol/L to reduce hypoglycaemia frequency*** - In cases of **recurrent severe hypoglycaemia** in pregnancy, **NICE guidelines** recommend relaxing blood glucose targets (fasting <6.0 mmol/L and 1-hour post-prandial <8.5 mmol/L) to ensure maternal safety. - While tight control is vital to prevent **macrosomia** and **congenital abnormalities**, problematic hypoglycaemia takes clinical priority and requires target adjustment. *Reduce basal insulin doses by 10-20% and accept slightly higher fasting glucose readings to prevent hypoglycaemia* - Adjusting insulin doses alone without formally **revising glucose targets** fails to address the underlying goal of treatment modifications in these patients. - Reducing insulin arbitrarily may lead to **hyperglycaemic peaks** if clinical targets are not systematically relaxed and monitored. *Switch to continuous subcutaneous insulin infusion (pump therapy) to reduce hypoglycaemia risk* - **CSII (Pump therapy)** can improve glycaemic variability, but it is not the immediate first-line response to severe hypoglycaemia when current **targets are too aggressive**. - Initiating pump therapy requires time for training and adjustment, whereas **relaxing targets** provides an immediate safety intervention. *Continue current regimen as hypoglycaemia is expected in first and second trimester with tight control* - While insulin sensitivity changes during pregnancy, **severe hypoglycaemia requiring assistance** is never an "expected" or acceptable outcome. - Failing to act on recurrent severe episodes puts the patient at risk of **hypoglycaemia unawareness** and life-threatening events. *Add continuous glucose monitoring with hypoglycaemia alerts but maintain current targets and insulin doses* - **CGM** is useful for identifying patterns, but it does not fix the fundamental issue of **targets being set too low** for this specific patient's physiology. - Alerts may reduce the severity of episodes, but they do nothing to reduce the **frequency of hypoglycaemia** if the physiological targets remain overly tight.
Question 90: A 33-year-old woman with Graves' disease has been taking carbimazole 20mg once daily for 6 months. She now presents with a 2-day history of sore throat, fever, and general malaise. Examination shows temperature 38.4°C, pulse 92 bpm, and pharyngeal erythema. What is the most appropriate immediate management?
- A. Continue carbimazole and prescribe oral penicillin V for pharyngitis
- B. Stop carbimazole immediately and arrange urgent full blood count (Correct Answer)
- C. Reduce carbimazole dose to 10mg daily and review in 1 week
- D. Continue carbimazole, arrange routine blood tests, and prescribe symptomatic treatment
- E. Stop carbimazole and commence propylthiouracil as alternative antithyroid drug
Explanation: ***Stop carbimazole immediately and arrange urgent full blood count***- **Agranulocytosis** is a rare but life-threatening side effect of **carbimazole**, and a sore throat with fever in a patient on this medication must be treated as a medical emergency.- The drug must be **stopped immediately**, and an **urgent Full Blood Count (FBC)** is required to check for a **neutrophil count** (typically <0.5 x 10⁹/L in agranulocytosis).*Continue carbimazole and prescribe oral penicillin V for pharyngitis*- Prescribing antibiotics without checking the blood count is dangerous as it may mask **sepsis** while the underlying **bone marrow suppression** continues.- Carbimazole must not be continued if there is any clinical suspicion of **agranulocytosis** until the FBC result is known.*Reduce carbimazole dose to 10mg daily and review in 1 week*- **Agranulocytosis** is an idiosyncratic reaction, not strictly dose-dependent; merely reducing the dose does not eliminate the risk of fatal infection.- Waiting one week for review is inappropriate as **neutropenic sepsis** can progress rapidly and lead to death within days.*Continue carbimazole, arrange routine blood tests, and prescribe symptomatic treatment*- Routine blood tests take too long; **urgent medical attention** is required to prevent severe infection in an immunocompromised patient.- Symptomatic treatment alone fails to address the potentially lethal drop in **white blood cells** caused by the medication.*Stop carbimazole and commence propylthiouracil as alternative antithyroid drug*- **Propylthiouracil** (PTU) also carries a significant risk of agranulocytosis and frequently shows **cross-reactivity** with carbimazole-induced bone marrow suppression.- Switching to another thionamide is contraindicated if the patient has experienced a severe reaction like agranulocytosis with the first drug.
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