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

1. A 28-year-old woman was referred with an 8-year history of progressive weight gain, hypertension and abdominal striae. She had no family history of note and was not taking any medication.
On examination, her blood pressure was 158/86 mmHg. There was central obesity with abdominal striae. There was mild proximal myopathy of the lower limbs.
Investigations:
serum sodium143 mmol/L (137-144)
serum potassium3.4 mmol/L (3.5-4.9)
low-dose dexamethasone suppression test (2 mg/day for 48 h):
serum cortisol180 nmol/L (<50)
An MR scan of pituitary showed an invasive adenoma extending laterally into the cavernous sinuses bilaterally. Superiorly, the adenoma was in contact with, but not distorting, the optic chiasm. Formal visual field examination was normal.
What is the most appropriate next step in management?

A) bilateral adrenalectomy
B) adrenolytic therapy
C) pituitary radiotherapy
D) trans-sphenoidal hypophysectomy
E) somatostatin agonist therapy

2. A 45-year-old man had type 2 diabetes mellitus of 2 years' duration. He had no history of ischaemic heart disease or microvascular complications, and was euthyroid. There was no family history of ischaemic heart disease. He was a non-smoker and drank 4 to 8 units of alcohol per week. He was taking metformin only.
On examination, his blood pressure was 120/78 mmHg and his body mass index was 24 kg/m2 (18-25).
His calculated 10-year cardiovascular risk was 8.5%.
Investigations (fasting):
serum sodium142 mmol/L (137-144)
serum potassium3.8 mmol/L (3.5-4.9)
serum creatinine90 umol/L (60-110)
haemoglobin A1c48 mmol/L (20-42)
urinary albumin:creatinine ratio1.5 mg/mmol (<2.5)
serum cholesterol5.1 mmol/L (<5.2)
serum HDL cholesterol1.50 mmol/L (>1.55)
fasting serum triglycerides1.22 mmol/L (0.45-1.69)
What does the NICE guidance (CG181, July 2014) on type 2 diabetes mellitus recommend as the most appropriate next step in management?

A) atorvastatin
B) simvastatin
C) micronised fenofibrate
D) no change
E) omega-3 marine triglycerides

3. A 55-year-old woman presented complaining of difficulty losing weight.
On examination, her blood pressure was 170/105 mmHg and urinalysis showed protein 1+.
An ultrasound scan of abdomen revealed a 4.5-cm solid lesion in the right adrenal gland. She was treated with ramipril and further endocrine evaluation was performed.
Investigations:
serum potassium3.6 mmol/L (3.5-4.9)
serum creatinine135 umol/L (60-110)
plasma renin activity:
(after 30 min supine)3.9 pmol/mL/h (1.1-2.7)
(after 30 min upright)6.8 pmol/mL/h (3.0-4.3)
plasma aldosterone:
(after 30 min supine)150 pmol/L (135-400)
(after 4 h upright)350 pmol/L (330-830)
serum cortisol (09.00 h)650 nmol/L (200-700)
serum cortisol (22.00 h)225 nmol/L (50-250)
24-h urinary free cortisol230 nmol (55-250)
24-h urinary dopamine3200 nmol (<3100)
24-h urinary adrenaline120 nmol (<144)
24-h urinary noradrenaline450 nmol (<570)
What is the most appropriate initial management of the adrenal lesion?

A) surgical excision
B) mineralocorticoid receptor blockade
C) ?-adrenoceptor blockade
D) angiotensin-2 receptor blockade
E) medical observation with annual ultrasonography

4. A 37-year-old woman presented with a 2-year history of increasingly frequent flushing episodes. She described alternating loose bowel motions and constipation. She had also noted menstrual irregularity. She had no respiratory symptoms. She denied headache or chest pain, but complained of palpitations.
On examination, she appeared well. Her blood pressure was 128/82 mmHg.
Investigations:
serum thyroid-stimulating hormone0.8 mU/L (0.4-5.0)
What is the most appropriate next investigation?

A) urinary 5-hydroxyindoleacetic acid
B) fasting plasma gut hormones
C) serum gonadotrophins
D) plasma metanephrines
E) urinary metanephrines

5. A 28-year-old man was seen in the lipid clinic following a referral from the general surgical team. He had had two episodes of acute pancreatitis over the preceding 6 months, which settled spontaneously. He had a past medical history of HIV disease and was taking highly active antiretroviral (HAART) therapy. He drank 12 units of alcohol per week.
On examination, he had no stigmata of hyperlipidaemia.
Investigations:
fasting plasma glucose6.2 mmol/L (3.0-6.0)
haemoglobin A1c44 mmol/mol (20-42)
serum cholesterol7.5 mmol/L (<5.2)
fasting serum triglycerides23.70 mmol/L (0.45-1.69)
serum thyroid-stimulating hormone0.7 mU/L (0.4-5.0)
serum free T414.3 pmol/L (10.0-22.0)
What class of antiretroviral drug is the most likely cause of his metabolic disturbance?

A) protease inhibitors (e.g. ritonavir)
B) entry inhibitors (e.g. enfuvirtide)
C) nucleoside reverse transcriptase inhibitors (e.g. zidovudine)
D) integrase inhibitors (e.g. raltegravir)
E) non-nucleoside reverse transcriptase inhibitors (e.g. nevirapine)

Solutions: