Specialty Certificate Examination in Endocrinology and Diabetes Sample Questions Question: 1 A 32-year-old Latin American woman had an oral

glucose tolerance test in the 28th week of pregnancy. Her fasting plasma glucose was 6.0 mmol/L (3.06.0) and 2-hour plasma glucose was 11.3 mmol/L. Her current body mass index was 28 kg/m2. Weight gain in the pregnancy was 5 kg. There was no past history of gestational diabetes and no family history of diabetes. What is her approximate risk of developing type 2 diabetes mellitus by 5 years postpartum? A B C D E 1% 5% 10% 40% 90%

SCE E&D Sample Qs updated 01/12/11

Question: 2 A 45-year-old man was referred with a 6-week history of polyuria, polydipsia and 7-kg weight loss. One week previously, his general practitioner had diagnosed type 2 diabetes mellitus and had started treatment with metformin. He had made appropriate changes to his diet, but his fasting capillary blood glucose readings remained above 15 mmol/L (36). He was feeling tired but not otherwise unwell. He remained overweight with a body mass index of 34 kg/m2. Investigations: serum sodium serum potassium serum bicarbonate serum creatinine fasting plasma glucose urinalysis What is the most appropriate additional treatment? A B C D E exenatide gliclazide intravenous insulin infusion pioglitazone subcutaneous insulin 142 mmol/L (137144) 4.9 mmol/L (3.54.9) 23 mmol/L (2028) 102 mol/L (60110) 19.7 mmol/L (3.06.0) glycosuria 3+; ketonuria 2+

SCE E&D Sample Qs updated 01/12/11

Question: 3 A 55-year-old woman had previously been found to have a 4-cm papillary thyroid cancer. She had been treated with surgery and radio-iodine and subsequently had an undetectable thyroglobulin but a high titre of anti-thyroglobulin antibody. What is the most appropriate investigation at annual follow-up? A B C D E CT scan of neck PET scan of neck serum anti-thyroid peroxidase antibodies ultrasound scan of neck whole body iodine uptake scan

SCE E&D Sample Qs updated 01/12/11

Question: 4 A 78-year-old woman was referred for bone density assessment after developing acute mid-thoracic bone pain. She had previously been found to have osteoporosis after fracturing her right wrist after tripping in the street. She had also experienced two previous episodes of severe back pain that were thought to have been caused by vertebral fractures. She had lost 12.5 cm in height. Her mother had developed a severe kyphosis in her seventies. She had been taking alendronic acid, calcium and vitamin D regularly for 3 years. On examination, there was a mild thoracic kyphosis and tenderness over the T10 vertebra. Investigations: erythrocyte sedimentation rate serum creatinine serum corrected calcium serum alkaline phosphatase X-ray of thorax and lumbar spine 35 mm/1st h (<30) 105 mol/L (60110) 2.35 mmol/L (2.202.60) 95 U/L (45105) new crush fracture of T10, previously reported fractures of T8 and L1 T score 3.8 T score 3.4

DEXA scan of spine (L2L4) DEXA scan of total hip What is the most appropriate treatment? A B C D E continue alendronic acid hormone replacement therapy raloxifene strontium ranelate teriparatide

SCE E&D Sample Qs updated 01/12/11

Question: 5 A 43-year-old woman with a 2-year history of secondary amenorrhoea was seen in clinic at the request of her general practitioner, following the finding of hyperprolactinaemia. She had a long-standing history of hypothyroidism treated with 100 g of thyroxine, and depression treated with risperidone. Investigations: plasma prolactin plasma thyroid-stimulating hormone plasma free T4 MR scan of pituitary 1800 mU/L (<360) 7.8 mU/L (0.45.0) 9.0 pmol/L (10.022.0) no abnormalities reported

What is the most likely cause of her hyperprolactinaemia? A B C D E hypothyroidism microprolactinoma polycystic ovarian disease risperidone stress

SCE E&D Sample Qs updated 01/12/11

Question: 6 A 77-year-old woman sustained a low trauma fracture of her right wrist. Two years previously, she had fractured her proximal humerus. Investigations for secondary causes of osteoporosis revealed no abnormalities. Investigations: DEXA scan result: L1L4 L hip T-score 3.9 2.7

What cell type in bone primarily senses strain and microdamage? A B C D E adipocyte lining cell osteoblast osteoclast osteocyte

SCE E&D Sample Qs updated 01/12/11

Question: 7 A 36-year-old man of European descent was reviewed in the diabetes clinic. He had type 2 diabetes mellitus that had been diagnosed 6 months previously, He had been symptom free and had no family history of cardiovascular disease but was a smoker. On examination, his blood pressure was 138/76 mmHg, his weight was 90 kg and his body mass index was 32 kg/m2. Investigations: urinary albumin:creatinine ratio serum cholesterol serum HDL cholesterol fasting serum triglycerides 0.6 mg/mmol (<2.5) 5.3 mmol/L (<5.2) 0.9 mmol/L (>1.55) 2.2 mmol/L (0.450.69)

According to NICE guidelines May 2009, what is the most appropriate management of his lipid profile? A B C D E assess cardiovascular risk using UKPDS risk engine observe and repeat lipid profile in a few months start a fibrate start a statin start nicotinic acid

SCE E&D Sample Qs updated 01/12/11

Question: 8 A 32-year-old woman presented to the outpatient department with a 1-year history of amenorrhoea that began after stopping her oral contraceptive pill. She had experienced two successful pregnancies and was otherwise well. On examination, there was an upper outer quadrantanopia. Investigations: serum sodium serum potassium plasma follicle-stimulating hormone plasma luteinising hormone plasma prolactin MR scan of pituitary 138 mmol/L (137144) 3.8 mmol/L (3.54.9) 2 U/L (2.510.0) 2 U/L (2.510.0) 8450 mU/L (<360) 2-cm adenoma with suprasellar extension

What is the most appropriate management? A B C D E cabergoline conformal pituitary radiotherapy octreotide refer for pituitary surgery stereotactic pituitary radiosurgery

SCE E&D Sample Qs updated 01/12/11

Question: 9 A 26-year-old woman was admitted with diabetic ketoacidosis. After 24 hours of treatment with intravenous fluids, potassium and insulin, her normal subcutaneous insulin regimen was resumed. However, she felt nauseated and there was a concomitant increase in urine ketones (3+). On examination, her pulse was 118 beats per minute and her blood pressure was 106/66 mmHg. Investigations: serum sodium serum potassium serum bicarbonate serum creatinine random plasma glucose 136 mmol/L (137144) 4.4 mmol/L (3.54.9) 15 mmol/L (2028) 78 mol/L (60110) 7.3 mmol/L

What is the most appropriate next step in management? A B C D E increase subcutaneous basal insulin at bedtime increase subcutaneous bolus insulin with meals start glucose 5% with intravenous insulin start glucose 10% with intravenous insulin start intravenous insulin infusion with sliding scale

SCE E&D Sample Qs updated 01/12/11

Question: 10 An 18-year-old woman was referred by her general practitioner for further investigation of funny turns during which she developed palpitations, sweating, tremor, hunger, anxiety and paraesthesiae; all of these symptoms were relieved immediately by a sugary drink. She was otherwise well and was not taking any regular medication. There was a family history of diabetes mellitus. A spontaneous hypoglycaemic episode had not been captured and she was admitted to the diabetes/endocrine ward for a prolonged 72-hour fast. Her renal function was normal. After a 12-h fast she experienced her typical symptoms. Urinalysis showed no urinary ketones. Investigations after 12-h fast: fasting plasma glucose plasma insulin (after hypoglycaemia) serum C-peptide 2.0 mmol/L (3.06.0) 56 pmol/L (<21) 514 pmol/L (180360)

What is the most appropriate next step in management? A coeliac axis angiography B MR scan of abdomen and pelvis to localise a mesenchymal tumour producing insulinlike growth factor 2 C MR scan of pancreas to localise an insulinoma D obtain a careful history looking for access to exogenous insulin E request a urinary sulphonylurea screen

SCE E&D Sample Qs updated 01/12/11

Question 11 A 42-year-old woman was seen 6 weeks post partum. She had delivered a healthy baby weighing 3.9 kg at 38 weeks gestation and had begun breastfeeding, but she had recently found that she was no longer able to breastfeed. She had a 4-year history of type 2 diabetes mellitus. She had been treated with methyldopa for hypertension during the pregnancy. Because of a misunderstanding, she had also restarted her pre-pregnancy medication 4 days before clinic review. Her medication comprised simvastatin 40 mg daily, metformin 500 mg three times a day, gliclazide 80 mg twice a day and enalapril 10 mg daily. Which of her medications is most likely to have interfered with lactation? A B C D E enalapril gliclazide metformin methyldopa simvastatin

SCE E&D Sample Qs updated 01/12/11

Question 12 A 65-year-old man with type 2 diabetes mellitus presented to the foot clinic with a painful, red, swollen foot. His body mass index was 34 kg/m 2 (1825). An X-ray of the foot demonstrated neuroarthropathy (Charcots foot). What is the most important reason for treatment with intravenous bisphosphonate? A B C D E as an adjunct to surgery to improve the outcome to reduce deformity in the long term to reduce pain to reduce the risk of contralateral Charcots foot to reduce the time to resolution

SCE E&D Sample Qs updated 01/12/11

Question 13 A 30-year-old woman with type 2 diabetes mellitus reported that her younger brother had recently been found to have the same condition. Both her father and paternal grandfather had been treated with insulin. Her father had been found to have multiple kidney cysts on ultrasound scan. What gene mutation is most likely to be responsible for this pedigree? A B C D E GCK HNF1 HNF1 HNF4 KCNJ11

SCE E&D Sample Qs updated 01/12/11

Question 14 A 64-year-old woman with a 20-year history of type 2 diabetes mellitus presented following the sudden onset of a painful right eye. She had noticed drooping of her right eyelid but no double vision. There were no other neurological symptoms. On examination, there was a complete right-sided ptosis, with her eye position down and out. Her pupils were equal on both sides. Investigations: haemoglobin A1c MR scan of brain 57 mmol/mol (2042) no evidence of any intracranial pathology

She was worried about her long-term prognosis and outcome. What is the most likely prognosis? A B C D E her condition is likely to deteriorate before it improves her prognosis is uncertain and depends upon metabolic control she is at risk of progression, and the other eye might also be affected she is likely to be left with a permanent ptosis she is likely to make a very good recovery

SCE E&D Sample Qs updated 01/12/11

Question 15 A 49-year-old woman presented with progressive loss of vision in both eyes. She was otherwise well and her only medication was hormone replacement therapy. Examination showed bitemporal hemianopia. Investigations: serum osmolality urinary osmolality serum cortisol (09.00 h) serum follicle-stimulating hormone serum luteinising hormone serum prolactin serum thyroid-stimulating hormone serum free T4 MR scans of brain (pre- and post-contrast) 296 mosmol/kg (278300) 120 mosmol/kg (3501000) 456 nmol/L (200700) 1.3 U/L (2.510.0) 2.0 U/L (2.510.0) 1123 mU/L (<360) 2.3 mU/L (0.45.0) 18.1 nmol/L (10.022.0) see images a and b

(a)

(b)

What is the most likely cause of her loss of vision? A B C D E craniopharyngioma meningioma non-functioning pituitary adenoma prolactinoma Rathkes cleft cyst

SCE E&D Sample Qs updated 01/12/11

Question 16 A 35-year-old woman was referred with a left lower thyroid lesion. She was asymptomatic. Examination confirmed the presence of a 2 Investigations: fine-needle aspiration biopsy How is Thy 3 defined? A B C D E abnormal; diagnostic of malignancy abnormal; suspicious (but not diagnostic of) malignancy follicular lesions non-diagnostic or inadequate non-neoplastic (consistent with nodular goitre or thyroiditis) Thy 3 3-cm, firm, mobile, non-tender mass.

SCE E&D Sample Qs updated 01/12/11

Question 17 An 18-year-old man was referred with recently diagnosed hypertension. He had no previous history of note and was taking no medication. His father had been found to have hypertension in his twenties after sustaining a brain haemorrhage. On examination, his blood pressure was raised at 190/110 mmHg. Investigations: serum sodium serum potassium plasma renin activity (after 30 min supine) plasma aldosterone (after 30 min supine) urinary 18-oxocortisol What is the most appropriate investigation? A B C D E adrenal venous sampling aldosterone suppression test captopril test CT scan of adrenal glands genetic testing 142 mmol/L (137144) 3.4 mmol/L (3.54.9) 0.2 pmol/mL/h (1.12.7) 450 pmol/L (135400) 32 nmol/mmol creatinine (0.86.5)

SCE E&D Sample Qs updated 01/12/11

Question 18 A 24-year-old woman was admitted with confusion of 24 hours duration. She had been feverish with episodic vomiting for 48 hours. She had lost 10 kg in weight over the previous 4 months, and had a poor appetite. She had become progressively fatigued and had been made redundant from her cleaning job 7 weeks previously. On examination, her pulse was 93 beats per minute and regular, and her blood pressure was 93/64 mmHg. She was disorientated, with a Glasgow coma score of 11, but there were no focal neurological signs. She was thin with a body mass index of 17 kg/m2 (18 25). Examination was otherwise normal. Investigations: serum sodium serum potassium serum bicarbonate serum urea serum creatinine serum corrected calcium fasting plasma glucose serum cortisol (09.00 h) serum thyroid-stimulating hormone serum free T4 What is the most appropriate intravenous therapy? A B C D E aciclovir disodium pamidronate hydrocortisone metoclopramide sodium chloride 0.9% 119 mmol/L (137144) 5.0 mmol/L (3.54.9) 18 mmol/L (2028) 9.7 mmol/L (2.57.0) 134 mol/L (60110) 3.20 mmol/L (2.202.60) 3.3 mmol/L (3.06.0) 192 nmol/L (200700) 8.3 mU/L (0.45.0) 13.6 pmol/L (10.022.0)

SCE E&D Sample Qs updated 01/12/11

Question 19 A 35-year-old woman presented with a 6-month history of diffuse bone pain. Hypophosphataemic rickets had been diagnosed in childhood and she had been taking oral phosphate supplements since. She was currently taking two Phosphate-Sandoz tablets four times per day. On examination, a proximal myopathy was present. Investigations: serum creatinineBanked into FAIM serum corrected calcium serum phosphate serum alkaline phosphatase plasma parathyroid hormone serum 25-OH-cholecalciferol What is most appropriate treatment? A B C D E add calcitriol add cinacalcet increase oral phosphate intravenous phosphate parathyroidectomy 105 mol/L (60110) 2.35 mmol/L (2.202.60) 0.6 mmol/L (0.81.4) 344 U/L (45105) 9.5 pmol/L (0.95.4) 85 nmol/L (4590)

SCE E&D Sample Qs updated 01/12/11

Question 20 A 27-year-old woman presented 10 weeks into her first pregnancy with tremor, sweats, diarrhoea and no vomiting. On examination, there was a fine tremor, her pulse was 110 beats per minute and regular, and her peripheries were hot and moist. She had a moderate diffuse goitre and there was no thyroid-associated ophthalmopathy. Investigations: serum thyroid-stimulating hormone serum free T4 <0.1 mU/L (0.45.0) 67.7 pmol/L (10.022.0)

What is the most appropriate treatment for her thyrotoxicosis? A B C D E carbimazole 20 mg once daily carbimazole 20 mg once daily and levothyroxine 100 micrograms once daily propylthiouracil 100 mg twice a day propylthiouracil 100 mg twice a day and levothyroxine 100 micrograms once daily propylthiouracil 200 mg twice a day and levothyroxine 200 micrograms once daily

SCE E&D Sample Qs updated 01/12/11

Question 21 A 16-year-old girl was referred with primary amenorrhoea. She was otherwise healthy but reported significant weight gain over the past 2 years. On examination, she had minor facial hirsutism and a blood pressure of 138/68 mmHg. Her body mass index was 29 kg/m2 (1825). Investigations: serum 17-hydroxyprogesterone serum oestradiol serum testosterone serum sex hormone binding protein serum follicle-stimulating hormone serum luteinising hormone serum prolactin What is the most likely diagnosis? A B C D E 21-hydroxylase deficiency Cushings syndrome polycystic ovary syndrome prolactinoma Turners syndrome 7 nmol/L (110) 280 pmol/L (200400) 2.9 nmol/L (0.53.0) 19 nmol/L (40137) 4.0 U/L (2.510.0) 6.0 U/L (2.510.0) 600 mU/L (<360)

SCE E&D Sample Qs updated 01/12/11

Question 22 A 19-year-old woman presented to her general practitioner with secondary amenorrhoea of 3 months duration. There was no history of weight loss or hirsutism and there had been no previous menstrual disturbance. She was taking no medication and was otherwise well. On examination, there was no galactorrhoea and no visual loss. Investigations: serum cortisol (09.00 h) serum oestradiol serum testosterone serum follicle-stimulating hormone serum luteinising hormone serum prolactin serum thyroid-stimulating hormone serum free T4 What is the most likely diagnosis? A B C D E macroprolactinaemia microprolactinoma partial hypopituitarism polycystic ovary syndrome pregnancy 459 nmol/L (200700) 1500 nmol/L (200400) 1.6 nmol/L (0.53.0) <0.3 U/L (2.510.0) <0.3 U/L (2.510.0) 1205 mU/L (<360) 0.5 mU/L (0.45.0) 14.1 pmol/L (10.022.0)

SCE E&D Sample Qs updated 01/12/11

Question 23 A 48-year-old bus driver attended a diabetes clinic for review. He was taking metformin and gliclazide and had been intolerant of other oral medication. There were no complications of diabetes and he had never experienced hypoglycaemia. He had held a Group 2 (vocational) driving licence for 5 years but had never informed the Driver and Vehicle Licensing Agency (DVLA) of his diabetes. He was advised to start insulin. What advice should be given about driving? A he may be able to hold a Group 2 licence and can continue driving a bus but must inform the DVLA as soon as possible B he may be able to hold a Group 2 licence but should stop driving a bus immediately and inform the DVLA C he may wish to inform the DVLA but does not need by law to do so unless he develops complications of diabetes D he will not be able to hold a Group 2 licence and must stop driving a bus immediately E he will not be able to hold a Group 2 licence but may apply to DVLA for an alternative licence to allow him to continue driving a bus

SCE E&D Sample Qs updated 01/12/11

Question 24 A 38-year-old woman presented with a goitre. It had been growing steadily for the past 4 months. She described a 3-month history of worsening dysphagia and had experienced choking on lying down. She had unintentionally lost 3 kg in weight. On examination, she was clinically euthyroid and had a large, smooth, non-tender goitre with retrosternal extension. Investigations: serum thyroid-stimulating hormone serum free T4 serum anti-thyroid peroxidase antibodies fine-needle aspiration cytology CT scan of neck 3.2 mU/L (0.45.0) 19.8 pmol/L (10.022.0) 19.8 IU/mL (<50) Thy2 see image

What is the most appropriate next step in management? A B C D E high-dose radioactive iodine therapy levothyroxine therapy pulmonary flow loops refer for thyroidectomy technetium-99m thyroid uptake scan

SCE E&D Sample Qs updated 01/12/11

Answers: 1. D 2. E 3. D 4. E 5. D 6. E 7. D 8. A 9. D 10. E 11. D 12. C 13. C 14. E 15. A 16. C 17. E 18. C 19. A 20. C 21. C 22. E 23. D 24. D

SCE E&D Sample Qs updated 01/12/11