SEND - Endocrinology and Diabetes Questions + Answers

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Question 1
An 18-year-old woman presented with a 2-month history of polyuria and polydipsia. She had been previously fit and well with regular periods. She was not taking any contraception.
Investigations:
serum potassium5.2 mmol/L (3.54.9)
serum corrected calcium2.30 mmol/L (2.202.60)
serum cortisol (09.00 h)350 nmol/L (200700)
She went on to have a water deprivation test, the results of which are detailed below. time (h)serum osmolality (mosmol/kg)urine osmolality (mosmol/kg) normal: 278300normal: 1001000
08.3028952
11.3029282
14.30301153
15.30-172
She was then given intramuscular DDAVP 2 micrograms at 16.00 h. time (h)serum osmolality (mosmol/kg)urine osmolality (mosmol/kg) normal: 278300normal: 1001000
16.30300-
17.30-530
18.30-532
Results from an MR scan of pituitary are shown (see image).



What is the most likely diagnosis?
A. autoimmune (lymphocytic) hypophysitis
B. craniopharyngioma
C. non-functioning pituitary adenoma
D. psychogenic polydipsia
E. Rathke’s cleft cyst


Answer : A

Question 2
An 18-year-old man with cystic fibrosis was referred to clinic. Over recent months his lung function had deteriorated and he had lost weight. He was being treated for a chest infection at the time of the consultation.
Investigations:
oral glucose tolerance test (75 g):
fasting plasma glucose8.2 mmol/L (3.06.0)
2-h plasma glucose13.5 mmol/L (<7.8)
What is the most appropriate management?
A. repeat oral glucose tolerance test after chest infection has resolved
B. restrict refined carbohydrate intake
C. start gliclazide
D. start insulin
E. start sitagliptin


Answer : D

Question 3
A 25-year-old woman presented at 28 weeks gestation after a screening 75-g oral glucose tolerance test, which had shown a fasting plasma glucose of 5.6 mmol/L (3.06.0) and a 2- h plasma glucose of 9.8 mmol/L (<7.8). She had a family history of type 2 diabetes mellitus and a pre-pregnancy body mass index of 36 kg/m2 (1825). Home blood glucose monitoring had shown persistently raised blood glucose despite dietary modification. She refused insulin because of needle phobia and was concerned about drug exposure to her unborn child.
The use of what hypoglycaemic therapy is acceptable in this situation?
A. exenatide
B. glibenclamide
C. gliclazide
D. pioglitazone
E. sitagliptin


Answer : B

Question 4
A 50-year-old man with a 9-year history of type 2 diabetes mellitus presented with excessive tiredness. His partner said that he snored excessively. His haemoglobin A1c was usually between 64 and 75 mmol/mol (2042). He was taking glimepiride 4 mg daily and orlistat. He was intolerant of metformin.
On examination, he had reduced sensation to a 10-g monofilament, and extensive background diabetic retinal changes. His Epworth sleepiness score was 13/24. His body mass index was 36 kg/m2 (1825) despite compliance with orlistat.
According to the NICE guidelines (CG87, May 2009), what is the most appropriate treatment?
A. acarbose
B. bariatric surgery
C. basal bolus insulin
D. dipeptidyl peptidase-4 inhibitor
E. glucagon-like peptide-1 agonist


Answer : E

Question 5
A 26-year-old man presented urgently, complaining of muscle pains. He had been found to have heterozygous familial hypercholesterolaemia 2 years previously owing to a mutation in the PCSK9 gene. He had a strong family history of premature vascular disease. He was taking atorvastatin 80 mg daily.
Investigations:
serum creatine kinase2782 U/L (24195)
serum cholesterol5.7 mmol/L (<5.2)
After stopping atorvastatin, his serum creatine kinase fell to within the normal range.
What is the most appropriate next step in management?
A. restart atorvastatin 10 mg
B. restart atorvastatin 40 mg
C. start ezetimibe 10 mg
D. start fenofibrate 100 mg
E. start fluvastatin 40 mg


Answer : E


Question 6
A 17-year-old boy was concerned about his height. He had been treated for Crohns disease since the age of 13 with a combination of topical and systemic corticosteroids and azathioprine. He was currently taking mercaptopurinE.
On examination, his height was on the 25th centile.
Investigations:

X-ray of right kneesee image -



What is the most appropriate next step in management?
A. advise him that growth is complete
B. advise him that he will continue to grow for 12 months
C. investigate for growth hormone deficiency
D. refer for leg lengthening surgery
E. treat with growth hormone


Answer : A

Question 7
A 78-year-old man presented with confusion, lethargy and thirst. He had hypertension treated with lisinopril 20 mg daily.
On examination, he was dehydrated. His pulse was 110 beats per minute and his blood pressure was 84/40 mmHg. Urinalysis showed ketones 1+.
Investigations:
serum sodium155 mmol/L (137144)
serum potassium5.2 mmol/L (3.54.9)
serum bicarbonate17 mmol/L (2028)
serum urea40.0 mmol/L (2.57.0)
serum creatinine358 mol/L (60110)
random plasma glucose78.0 mmol/L
He was treated with sodium chloride 0.9%. After 8 hours treatment, his urine output was
10 mL/h and his blood pressure was 121/50 mmHg.
Investigations (after 8 hours treatment):
serum sodium151 mmol/L (137144)
serum potassium4.9 mmol/L (3.54.9)
serum bicarbonate18 mmol/L (2028)
serum urea39.0 mmol/L (2.57.0)
serum creatinine347 mol/L (60110)
random plasma glucose48.0 mmol/L
What is the most appropriate next step in management?
A. compound lactate solution (Hartmann’s solution)
B. sodium chloride 0.18% and glucose 4%
C. sodium chloride 0.18% and glucose 5%
D. sodium chloride 0.45%
E. sodium chloride 0.9%


Answer : E

Question 8
A 35-year-old woman was referred with a left lower thyroid lesion. She was asymptomatic.
Examination confirmed the presence of a 2 ? 3-cm, firm, mobile, non-tender mass.
Investigations:
ultrasound-guided fine-needle aspiration biopsyThy 5
How is Thy 5 defined?
A. abnormal, diagnostic of malignancy
B. abnormal, suspicious (but not diagnostic of) malignancy
C. follicular lesions
D. non-diagnostic or inadequate
E. non-neoplastic (consistent with nodular goitre or thyroiditis)


Answer : A

Question 9
A 52-year-old man had been found to have type 1 diabetes mellitus at the age of 25. He had developed retinopathy at the age of 31 and a painless foot ulcer at the age of 40. His renal function had subsequently deteriorated.
On examination, urinalysis showed protein 1+, glucose 2+.
What is the most likely diagnosis?
A. focal segmental glomerulosclerosis
B. membranoproliferative glomerulonephritis
C. minimal change glomerulonephritis
D. nodular glomerulosclerosis
E. tubulointerstitial nephritis


Answer : D

Question 10
A 19-year-old man presented with late development of his pubic and axillary hair. He was otherwise well and was not taking any medication. His serum testosterone concentration had been normal on two previous occasions.
On examination, he now had post-pubertal secondary sexual characteristics. He had 1520 mL testes.
Investigations:
serum testosterone27.0 nmol/L (9.035.0)
serum sex hormone binding globulin28 nmol/L (1062)
serum follicle-stimulating hormone2.0 U/L (1.07.0)
serum luteinising hormone2.9 U/L (1.010.0)
What is the chief product of the Sertoli cell?
A. anti-Müllerian hormone
B. kisspeptin
C. oestrogen
D. serum sex hormone binding globulin
E. testosterone


Answer : A


Question 11
A 25-year-old man presented with a 2-month history of thirst and polyuria. He had minimal weight loss and his body mass index was 26 kg/m2 (1825). He had had sensorineural deafness since childhood. There was a very strong family history of sensorineural deafness and type 2 diabetes mellitus.
Urinalysis showed no ketones.
Investigations:
random plasma glucose18.0 mmol/L
What is the most appropriate next step in management?
A. genetic testing for maturity-onset diabetes of the young
B. measurement of glutamic acid decarboxylase antibodies
C. test for HFE genotype
D. test for mitochondrial diabetes
E. water deprivation test to assess posterior pituitary function


Answer : D

Question 12
A 34-year-old woman with a 21-year history of type 1 diabetes mellitus had started treatment with subcutaneous insulin pump therapy 18 months previously. Her haemoglobin
A1c before starting pump therapy was 77 mmol/mol (2042) and she had experienced severe hypoglycaemic events without warning symptoms over the previous 4 years.
At review in clinic, she reported continuing episodes of severe hypoglycaemia without warning symptoms despite regular monitoring and advice from her insulin pump nurse specialist.
On examination, her blood pressure was 134/80 mmHg and fundoscopy revealed moderate background diabetic retinopathy. Examination of the feet revealed strong, palpable pedal pulses and early evidence of sensory neuropathy.
Investigations:
estimated glomerular filtration rate (MDRD)24 mL/min/1.73 m2 (>60) haemoglobin A1c56 mmol/mol (2042)
24-h urinary total protein2.3 g (<0.2)
What is the most appropriate next step in management?
A. change to intensified subcutaneous insulin injections
B. refer for allogeneic pancreas transplantation
C. refer for allogeneic pancreatic islet cell transplantation
D. refer for combined pancreas and kidney transplantation
E. refer for continuous glucose monitoring


Answer : D

Question 13
A 34-year-old woman presented with palpitations, heat intolerance and a slight tremor. She was 9 weeks into her first pregnancy. She had not had any morning sickness.
On examination, her pulse was 100 beats per minute. She had a small uniform goitre but no tremor and no eye signs.
Investigations:
serum thyroid-stimulating hormone<0.01 mU/L (0.45.0)
serum free T442.0 pmol/L (10.022.0)
serum free T315.0 pmol/L (3.07.0)
anti-thyroid-stimulating hormone receptor
antibodies14 U/L (<7)
The decision was taken to treat her Graves disease with propylthiouracil (PTU) rather than carbimazole.
What is the reason for this decision?
A. concordance with PTU is greater
B. PTU does not cross the placenta
C. PTU is less associated with agranulocytosis
D. PTU is less associated with aplasia cutis
E. PTU is less associated with hepatitis


Answer : D

Question 14
A 41-year-old man presented to his general practitioner with symptoms of palpitations, sweating and anxiety. His blood pressure was 160/102 mmHg. He was advised to take propranolol 40 mg twice daily but was admitted to hospital later that week with an episode of pulmonary oedema.
On examination at the time of admission, he was noted to be pale and sweating and he had a blood pressure of 210/124 mmHg. A phaeochromocytoma was suspected.
What is the most likely cause of the cardiovascular deterioration following administration of propranolol?
A. ?1-adrenoceptor blockade leading to acute left ventricular dysfunction
B. inadequate ?-adrenoceptor blockade because of the short half-life of the drug
C. inhibition of catechol-O-methyltransferase by propranolol leading to an increase in circulating noradrenaline
D. loss of ?2-adrenoceptor-mediated vasodilatation
E. propranolol acting as an agonist at ?1-adrenoceptors


Answer : D

Question 15
A 17-year-old girl was referred to the transition clinic. She was taking hydrocortisone 10 mg twice daily and fludrocortisone 150 micrograms daily following a failed short tetracosactide
(Synacthen) test 5years previously. She had entered puberty at the age of 10 but had never achieved adult breast development or menarche.
Investigations:
haemoglobin95 g/L (115165)
MCV124 fL (8096)
white cell count8.4 ? 109/L (4.011.0)
platelet count334 ? 109/L (150400)
serum sodium138 mmol/L (137144)
serum potassium4.4 mmol/L (3.54.9)
serum urea3.5 mmol/L (2.57.0)
serum corrected calcium1.80 mmol/L (2.202.60)
serum follicle-stimulating hormone67.9 U/L (2.510.0)
serum luteinising hormone56.4 U/L (2.510.0)
What is the most likely diagnosis?
A. atypical congenital adrenal hyperplasia
B. autoimmune polyglandular syndrome type 1
C. hypothalamic germinoma
D. pituitary stalk interruption syndrome
E. Turner’s syndrome


Answer : B


Question 16
A 29-year-old woman presented with primary infertility, having had unprotected sexual intercourse for 15 months. Menarche had occurred at the age of 13.5 years. Her menstrual cycle was irregular, occurring every 2060 days. There was no history of galactorrhoea.
She denied abnormal hair growth.
On examination, her body mass index was 28.9 kg/m2 (1825) and she had normal secondary sexual characteristics. Her visual fields were full to confrontation.
Investigations:
serum androstenedione12.8 nmol/L (0.68.8)
serum oestradiol205 pmol/L (200400)
serum testosterone2.4 nmol/L (0.53.0)
serum sex hormone binding globulin23 nmol/L (40137)
serum follicle-stimulating hormone4.3 U/L (2.510.0)
serum luteinising hormone8.5 U/L (2.510.0)
serum prolactin420 mU/L (<360)
hysterosalpingogrampatent fallopian tubes
partners semen analysisnormal sperm count and motility
What is the most appropriate first-line intervention?
A. cabergoline
B. human chorionic gonadotropin
C. human menopausal gonadotropins
D. metformin
E. orlistat


Answer : D

Question 17
A 26-year-old physiologist was seen in the diabetes outpatient clinic. She had type 1 diabetes mellitus of 9 months duration, treated with subcutaneous insulin.
She asked what symptoms of hypoglycaemia she might experience.
In what order are responses to hypoglycaemia most likely to occur as blood glucose falls?
A. autonomic, counter-regulatory hormones, neuroglycopenia
B. autonomic, neuroglycopenia, counter-regulatory hormones
C. counter-regulatory hormones, autonomic, neuroglycopenia
D. counter-regulatory hormones, neuroglycopenia, autonomic
E. neuroglycopenia, autonomic, counter-regulatory hormones


Answer : C

Question 18
A 55-year-old woman was referred with a 6-month history of type 2 diabetes mellitus. She was not taking any regular medication. She was a non-smoker. She drank 10 units of alcohol per week. Her general practitioner had arranged for her to see the community dietician as the patient had made significant changes to her diet.
On examination, she was obese with a body mass index of 31.8 kg/m2 (1825). Her liver was not palpable.
Investigations:
serum ferritin310 g/L (15300)
serum total bilirubin16 mol/L (122)
serum alanine aminotransferase80 U/L (535)
serum aspartate aminotransferase75 U/L (131)
serum alkaline phosphatase150 U/L (45105)
serum gamma glutamyl transferase35 U/L (435)
haemoglobin A1c67 mmol/mol (2042)
serum cholesterol6.2 mmol/L (<5.2)
serum HDL cholesterol0.90 mmol/L (>1.55)
fasting serum triglycerides2.50 mmol/L (0.451.69)
What is the most appropriate management of her dyslipidaemia?
A. ezetimibe
B. fenofibrate
C. metformin
D. omega-3-acid ethyl esters
E. simvastatin


Answer : E

Question 19
A 35-year-old man presented with newly diagnosed type 2 diabetes mellitus. He had no medical history of note.
When should he inform the UK Driver and Vehicle Licensing Agency (DVLA) of his medical condition?
A. if he becomes unable to read a car number plate with one eye at 20.5 m
B. if he requires laser treatment to one eye
C. if he starts taking an oral hypoglycaemic agent
D. if he starts using basal night-time insulin
E. immediately


Answer : D

Question 20
A 62-year-old man with newly diagnosed type 2 diabetes mellitus presented with weight loss and anaemia.
On examination, the only abnormalities were evidence of recent weight loss and a red- brown rash on his lower limbs. Urinalysis showed glucose 3+.
Investigations:
serum total bilirubin19 mol/L (122)
serum aspartate aminotransferase26 U/L (131)
serum alkaline phosphatase98 U/L (45105)
serum gamma glutamyl transferase26 U/L (<50)
plasma gastrin21 pmol/L (<55)
plasma glucagon246 pmol/L (<50)
plasma pancreatic polypeptide158 pmol/L (<300)
plasma vasoactive intestinal polypeptide12 pmol/L (<30)
chromogranin A214 U/L (<40)
serum thyroid-stimulating hormone4.9 mU/L (0.45.0)
serum free T49.1 pmol/L (10.022.0)
CT scan of abdomen2-cm mass in the tail of the pancreas
What is the most likely explanation for the rash?
A. acrodermatitis enteropathica
B. cutaneous metastasis
C. necrobiosis lipoidica diabeticorum
D. necrolytic migratory erythema
E. pellagra


Answer : D



10 questions per page
Question 21
A 43-year-old man was in an ENT ward, having recently undergone removal of a carotid body tumour. Five years previously, he had undergone a similar procedure in another hospital. He also recalled that his brother had undergone surgery for a similar condition, and that his father, who had since died, might also have had neck surgery.
The ENT surgeons were concerned that there might be an underlying genetic diagnosis.
What is the most likely diagnosis?
A. multiple endocrine neoplasia type 2
B. neurofibromatosis type 1
C. succinate dehydrogenase A deficiency
D. succinate dehydrogenase D deficiency
E. von Hippel–Lindau disease


Answer : D

Question 22
A 50-year-old woman noticed some swelling of her right great toe and a painful right foot.
She had type 1 diabetes mellitus of 21 years duration and recent screening had revealed some mild diabetic retinal changes and peripheral neuropathy.
On examination, she had a hot, red right forefoot with swelling of the great toe. There was callus on the first metatarsal head with a blister beneath it. After de-roofing, the podiatrist probed to a depth of 1 cm. The left foot demonstrated reduced sensation to a 10-g monofilament. Her right foot was 0.6C hotter than the left.
What is the most likely diagnosis?
A. Charcot’s foot
B. gout
C. necrotising fasciitis
D. osteoarthritis
E. osteomyelitis


Answer : E

Question 23
A 76-year-old woman with type 2 diabetes mellitus was reviewed. Treatment with thiazolidinedione was being considered, but she was worried about the effect this medication might have on the incidence of complications. She had known background retinopathy.
What complication is more likely to worsen in a patient taking a thiazolidinedione?
A. cataract
B. hard exudates
C. macular oedema
D. retinal haemorrhages
E. retinal vein thrombosis


Answer : C

Question 24
A 32-year-old man presented to the emergency department after becoming acutely unwell.
He had a 5-year history of type 1 diabetes mellitus and no other significant medical history.
On examination, he was apyrexial, his pulse was 120 beats per minute, his blood pressure was 96/58 mmHg and his respiratory rate was 32 breaths per minute.
Investigations:
random plasma glucose14.2 mmol/L
arterial blood gases, breathing 60% oxygen:
PO28.9 kPa (11.312.6)
PCO22.6 kPa (4.76.0)
pH7.10 (7.357.45)
H+79 nmol/L (3545)
bicarbonate6.1 mmol/L (2129)
base excess18 mmol/L (2)
What diagnosis is most likely to account for these results?
A. acute asthma
B. acute myocardial infarction
C. diabetic ketoacidosis
D. diabetic ketoacidosis and pulmonary embolism
E. salicylate poisoning


Answer : D

Question 25
A 64-year-old woman presented with features of acromegaly. An MR scan showed a pituitary tumour with cavernous sinus extension. She underwent trans-sphenoidal surgery and histology of the pituitary tissue showed numerous cells immunostaining for growth hormone.
Investigations (6 months postoperatively):
MR scan of pituitaryenlarged sella, residual tumour in right cavernous sinus serum growth hormone (day curve average)3.2 ?g/L (<2) serum insulin-like growth factor 142.0 nmol/L (3.323.3)
What is the most appropriate next step in management?
A. conventional external beam radiotherapy to pituitary region
B. long-acting octreotide
C. pegvisomant
D. repeat trans-sphenoidal surgery
E. watchful waiting


Answer : B


Question 26
A 73-year-old man had been attending the diabetes clinic for 6 weeks with an ulcer on his right second metatarsal head. He had been receiving regular podiatry and offloading.
What new feature in the appearance of his foot is most likely to suggest the need to start antibiotics?
A. increase in ulcer size
B. pain around ulcer
C. skin redness around ulcer
D. tracking sinus
E. ulcer probing to bone


Answer : C

Question 27
A 40-year-old man presented with a 4-month history of increasing central obesity. His medical history included HIV infection and allergic rhinitis. He was taking highly active antiretroviral therapy and nasal fluticasone.
On examination, he had marked central adiposity. His blood pressure was 160/95 mmHg.
Investigations:
serum sodium140 mmol/L (137144)
serum potassium3.8 mmol/L (3.54.9)
serum cholesterol5.5 mmol/L (<5.2)
fasting serum triglycerides8.20 mmol/L (0.451.69)
serum cortisol (09.00 h)<50 nmol/L (200700)
serum thyroid-stimulating hormone4.6 mU/L (0.45.0)
serum free T49.3 pmol/L (10.022.0)
What is the most likely diagnosis?
A. Addison’s disease
B. Cushing’s syndrome
C. glucocorticoid resistance
D. HIV-associated lipodystrophy
E. hypothyroidism


Answer : B

Question 28
A 54-year-old man was referred to the diabetes foot clinic with a plantar foot ulcer of 3 months duration under the right first metatarsal head. He had a 10-year history of type 2 diabetes mellitus. He lived alone and had to do his own shopping and cleaning.
On examination, the ulcer was 3 ? 2 cm in area, 4 mm in depth, and had a clean granulating base. He had strong palpable pedal pulses and sensory neuropathy in both feet.
What is the most effective intervention to heal this ulcer?
A. ambulatory vacuum-assisted pump therapy
B. long-term oral antibiotics
C. Manuka honey-impregnated wound dressing
D. removable pressure-relieving boot
E. total contact casting


Answer : E

Question 29
A 34-year-old man was referred to the diabetes outpatient clinic with impaired glucose tolerance. He had a family history of diabetes mellitus and had a body mass index of 34.6 kg/m2 (1825).
On examination, his blood pressure was 140/82 mmHg.
He wished to delay the onset of frank diabetes mellitus.
What is the most effective way of achieving this outcome?
A. acarbose
B. lifestyle changes aimed at weight loss
C. metformin
D. orlistat
E. ramipril


Answer : B

Question 30
Carbimazole is routinely used in the management of thyroid disease.
What does carbimazole inhibit?
A. deiodinase type 1
B. presentation of thyroid antigens to autoreactive T cells
C. sodium/iodide symporter
D. thyroglobulin synthesis
E. thyroid peroxidase


Answer : E

Question 31
A 56-year-old man presented with a 6-month history of erectile dysfunction. He had noticed a gradual reduction in his frequency of shaving from daily to twice a week. His libido had diminished and he felt that he was not as strong as he once was. He also described general aches and pains. He was a farm worker and had drunk a bottle of vodka daily for several years, but had stopped drinking 2 years previously. He was a non-smoker.
Investigations:
serum urea6.2 mmol/L (2.57.0)
serum creatinine89 mol/L (60110)
serum albumin40 g/L (3749)
serum total bilirubin17 mol/L (122)
serum alanine aminotransferase48 U/L (535)
serum aspartate aminotransferase37 U/L (131)
haemoglobin A1c55 mmol/mol (2042)
serum cortisol (09.00 h)389 nmol/L (200700)
serum testosterone0.7 nmol/L (9.035.0)
plasma follicle-stimulating hormone2.1 U/L (1.07.0)
plasma luteinising hormone2.4 U/L (1.010.0)
serum prolactin458 mU/L (<360)
serum thyroid-stimulating hormone3.4 mU/L (0.45.0)

MR scan of pituitarysee image -



What is the most likely explanation of his symptoms?
A. age-related hypogonadism
B. cirrhosis of liver
C. haemochromatosis
D. hyperprolactinaemia
E. pituitary adenoma


Answer : C

Question 32
A 54-year-old woman attended clinic for routine follow-up. She had Cushings syndrome secondary to ectopic adrenocorticotropic hormone syndrome with no primary source identified.
She had declined bilateral adrenalectomy. Routine medication included metyrapone 500 mg three times daily, ketoconazole 200 mg once daily and hydrocortisone 10 mg in the morning and 5 mg in the evening.
Metyrapone inhibits the action of which enzyme in steroidogenesis?
A. 3?-hydroxysteroid dehydrogenase
B. 5?-reductase
C. 11?-hydroxylase
D. 17?-hydroxylase
E. 21-hydroxylase


Answer : C

Question 33
A 57-year-old man was admitted to hospital with joint pains. He was found to have gout. He had been found to have type 2 diabetes mellitus at the age of 47 years and developed nephropathy 7 years later. He was taking metformin 1 g twice daily, ramipril 5 mg twice daily and gliclazide 80 mg twice daily. The admitting team advised him to take ibuprofen
400 mg three times daily as needed.
On examination, his pulse was 87 beats per minute and his blood pressure was 146/85 mmHg. He had an inflamed right hallux.
Investigations:
serum sodium131 mmol/L (137144)
serum potassium5.1 mmol/L (3.54.9)
serum creatinine156 mol/L (60110)
estimated glomerular filtration rate (MDRD)42 mL/min/1.73 m2 (>60) haemoglobin A1c72 mmol/mol (2042) random plasma glucose23.0 mmol/L
What is the most appropriate step in management?
A. stop gliclazide and ibuprofen
B. stop gliclazide and withhold metformin
C. stop ibuprofen alone
D. stop ibuprofen and withhold metformin
E. withhold metformin alone


Answer : D

Question 34
A 23-year-old woman presented to the outpatient clinic complaining of an inability to lose weight and irregular menses. Her food diary suggested that she consumed only 900 kilocalories daily. She had previously been found to have hypothyroidism and was treated with levothyroxine 75 micrograms daily.
On examination, her body mass index was 40.2 kg/m2 (1825).
Investigations:
serum testosterone3.6 nmol/L (0.53.0)
plasma follicle-stimulating hormone3.0 U/L (2.510.0)
plasma luteinising hormone9.0 U/L (2.510.0)
serum thyroid-stimulating hormone4.6 mU/L (0.45.0)
serum free T412.8 pmol/L (10.022.0)
What is the most appropriate next step?
A. add exenatide
B. add metformin
C. add orlistat
D. bariatric surgery
E. titrate levothyroxine dosage


Answer : E

Question 35
A 49-year-old woman presented with a mass in her neck that was causing no specific symptoms.
Examination revealed a solitary nodule in the right thyroid lobe, with no associated lymphadenopathy. Thyroid function was normal. No other abnormality was noted. There was no evidence of lymphadenopathy in the neck.
Investigations:
ultrasound scan of necksolid hypoechoic nodule 1.8 ? 1.2 ? 1 cm in right thyroid lobe; cyst 0.6 ? 0.3 ? 0.2 cm in left thyroid lobe cytology (fine-needle aspirationscanty colloid with abundant from nodule in right lobe)thyroid follicular cells (Thy3f)
What is the most appropriate next step in management?
A. reassure that the nodule is not malignant and discharge
B. repeat cytology for confirmation
C. serum thyroglobulin
D. thyroid lobectomy for histological diagnosis
E. total thyroidectomy for histological diagnosis


Answer : D


Question 36
A 63-year-old woman was incidentally found to have a 3-cm right adrenal mass on a CT scan of abdomen during investigation for abdominal pain. Her medical history included angina, hypertension and hypercholesterolaemia. She was taking oestrogen-containing hormone replacement therapy, atenolol, bendroflumethiazide, simvastatin and aspirin.
On examination, her pulse was 60 beats per minute and regular, and her blood pressure was 150/90 mmHg. She was obese with a body mass index of 34 kg/m2 (1825).
Fundoscopy revealed grade II hypertensive retinopathy.
Investigations:
serum sodium137 mmol/L (137144)
serum potassium3.0 mmol/L (3.54.9)
serum creatinine100 mol/L (60110)
plasma renin activity (after 30 min supine)0.4 pmol/mL/h (1.12.7) plasma aldosterone (after 30 min supine)200 pmol/L (135400) overnight dexamethasone suppression test (after 1 mg dexamethasone): serum cortisol75 nmol/L (<50)
24-h urinary free cortisol140 nmol (55250)
24-h urinary metanephrine<1 mol (<2)
24-h urinary normetanephrine1 mol (<3)
What is the most likely cause of the hypertension?
A. Conn’s syndrome
B. Cushing’s syndrome
C. essential hypertension
D. phaeochromocytoma
E. renovascular disease


Answer : C

Question 37
A 50-year-old woman with acromegaly presented with persistent sweating and headaches despite having undergone trans-sphenoidal surgery and pituitary radiotherapy 2 years previously. She had been intolerant of treatment with octreotide.
Investigations:
serum growth hormone11.1 ?g/L (<0.4)
serum insulin-like growth factor 186.2 nmol/L (5.623.3)
Following imaging, it was judged that there was no role for repeat surgery. She was treated with pegvisomant 10 mg. Six months into treatment, her symptoms had improved.
Investigations (6 months later):
serum growth hormone20.3 ?g/L (<0.4)
serum insulin-like growth factor 115.2 nmol/L (5.623.3)
What is the most appropriate next step in management?
A. add cabergoline
B. arrange another full course of pituitary radiotherapy
C. continue present dosage of pegvisomant
D. increase dosage of pegvisomant
E. stop pegvisomant


Answer : C

Question 38
A 48-year-old man presented with an infected ulcer, measuring 2 ? 1 cm, over the right first metatarsal head, with surrounding cellulitis. He had no previous history of diabetes mellitus but had been told by his general practitioner some years previously that his blood glucose was borderline.
On examination, his temperature was 37.4C, his blood pressure was 158/92 mmHg and his body mass index was 31.5 kg/m2 (1825). His foot pulses were easily palpable but he had a sensory neuropathy.
Investigations:
random plasma glucose16.4 mmol/L
haemoglobin A1c81 mmol/mol (2042)
What is the most appropriate treatment for his hyperglycaemia?
A. exenatide 5 micrograms twice daily
B. gliclazide 40 mg twice daily
C. metformin 500 mg twice daily
D. sitagliptin 100 mg once daily
E. soluble insulin before meals, basal insulin at bedtime


Answer : C

Question 39
A 72-year-old man with a dense residual hemiparesis and unsafe swallow was fed via a percutaneous gastrostomy for 20 hours each day. He resided in a nursing home and had type 2 diabetes mellitus that had been well controlled on metformin.
His glucose concentrations were uncontrolled on metformin powder at maximum dose.
While not being fed, his blood glucose was measured.
Investigations:
capillary blood glucose3.1 mmol/L
According to the Joint British Diabetes Societies Guidelines (2012), what is the most appropriate management?
A. Fortisip® 110 mL
B. Glucogel® ? 2 down gastrostomy tube
C. Glucogel® ? 2 given buccally
D. glucose 20% 150 mL intravenously
E. restart feed to deliver carbohydrate 20 g rapidly


Answer : E

Question 40
A 33-year-old woman was seen for diabetes review 2 months after her first pregnancy.
Diabetes mellitus had been diagnosed at 18 weeks gestation. She had experienced no symptoms; routine urinalysis had shown glucose 4+, with no ketones, and her fasting blood glucose concentration was 6.2 mmol/L (3.06.0), rising to 13.5 mmol/L (<7.8) in a 75-g oral glucose tolerance test. She had been treated with insulin during the pregnancy, and stopped after delivery. Her mother and maternal aunt had been treated for type 2 diabetes mellitus, and a maternal uncle for type 1 diabetes. Her body mass index was 23.7 kg/m2
(1825).
Without insulin she remained well, with no osmotic symptoms, no weight loss and no ketosis.
Investigations:
fasting plasma glucose8.4 mmol/L (3.06.0)
haemoglobin A1c68 mmol/mol (2042)
oral glucose tolerance test (75 g):
fasting plasma glucose7.9 mmol/L (3.06.0)
2-h plasma glucose13.8 mmol/L (<7.8)
serum insulin72 pmol/L (<186)
serum C-peptide945 pmol/L (180360)
A trial of therapy with gliclazide 40 mg once daily led to a significant improvement in her blood glucose.
What is the most likely cause of her diabetes?
A. latent autoimmune diabetes in adulthood
B. maturity-onset diabetes of the young caused by glucokinase mutation
C. maturity-onset diabetes of the young caused by HNF-1? mutation
D. type 1 diabetes mellitus
E. type 2 diabetes mellitus


Answer : C