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MRCPUK Endocrinology and Diabetes (Specialty Certificate Examination) Sample Questions:

1. A 54-year-old woman attended clinic for routine follow-up. She had Cushing's 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) 5?-reductase
B) 21-hydroxylase
C) 17?-hydroxylase
D) 3?-hydroxysteroid dehydrogenase
E) 11?-hydroxylase

2. 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 type 1 diabetes mellitus. A spontaneous hypoglycaemic episode had not been captured and she was admitted to the diabetes/endocrine ward for a 72-hour fast. Her renal function was normal.
After a 12-hour fast she experienced her typical symptoms. Urinalysis showed no urinary ketones.
Investigations after 12-h fast:
fasting plasma glucose 2.0 mmol/L (3.0-6.0)
plasma insulin56 pmol/L (<21 after hypoglycaemia)
serum C-peptide514 pmol/L (180-360)
What is the most appropriate next step in management?

A) coeliac axis angiography
B) request a urinary sulphonylurea screen on sample obtained during the fast
C) MR scan of pancreas to localise an insulinoma
D) obtain a careful history looking for access to exogenous insulin
E) MR scan of abdomen and pelvis to localise a mesenchymal tumour producing insulin-like growth factor 2

3. A 54-year-old man on the neurosurgery unit developed hyponatraemia 3 days after presenting with a significant head injury. His Glasgow coma score (GCS) had been 6 on admission.
On examination, his GCS was 12. His blood pressure was 124/84 mmHg. There was no
oedema.
Investigations:
serum sodium118 mmol/L (137-144)
serum urea3.0 mmol/L (2.5-7.0)
serum creatinine72 umol/L (60-110)
random serum cortisol (08.00 h on day of review)480 nmol/L
serum thyroid-stimulating hormone1.2 mU/L (0.4-5.0)
random urinary sodium60 mmol/L
What is the most appropriate interpretation of these data?

A) intravascular volume depletion
B) they are consistent with syndrome of inappropriate antidiuresis
C) the diagnosis would be helped by measurement of plasma vasopressin concentration
D) a short tetracosactide (Synacthen@) test (250 micrograms) is required to exclude secondary hypoadrenalism
E) the urinary sodium concentration is diagnostic of cerebral salt wasting

4. A 37-year-old woman was seen in clinic with a 2-month history of mild galactorrhoea. She had a long-standing history of hypothyroidism, treated with levothyroxine 125 micrograms daily, and a history of mental health issues, treated with risperidone. Her menstrual cycle was regular.
An MR scan of brain, requested elsewhere as part of a workup for headaches and other somatic symptoms, was available.
Investigations:
serum prolactin3000 mU/L (<360)
serum thyroid-stimulating hormone4.8 mU/L (0.4-5.0)
serum free T411.0 pmol/L (10.0-22.0)
MR scan of brainno abnormalities reported
What is the most appropriate next step in the management of her hyperprolactinaemia?

A) increase levothyroxine dosage
B) add cabergoline
C) MR scan of pituitary fossa
D) reassurance of no significant pituitary pathology
E) stop risperidone

5. 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 (137-144)
serum potassium5.1 mmol/L (3.5-4.9)
serum creatinine156 umol/L (60-110)
estimated glomerular filtration rate (MDRD)42 mL/min/1.73 m2 (>60)
haemoglobin A1c72 mmol/mol (20-42)
random plasma glucose23.0 mmol/L
What is the most appropriate step in management?

A) stop ibuprofen and withhold metformin
B) stop gliclazide and withhold metformin
C) stop gliclazide and ibuprofen
D) withhold metformin alone
E) stop ibuprofen alone

Solutions: