A 42-year-old woman is referred to the clinic with very difficult to manage hypertension. She is currently taking indapamide, ramipril, amlodipine and doxasosin, yet her blood pressure is still 155/95 mmHg. On examination she has a BMI of 25. Ophthalmoscopy reveals evidence of chronic changes consistent with hypertension. Bloods reveal;
Hb 14.0g/dl
WCC 5.8 x 109/L
PLT 190 x 109/L
Na+ 139mmol/l
K+ 3.3mmol/l
Creatinine 100 μmol/l
You suspect Conn’s syndrome.
Which of the following is the investigation of choice to confirm the diagnosis?
1- CT Abdomen
2- Iodine (I131) iodocholesterol scanning
3- Aldosterone:renin ratio
4- MRI abdomen
5- Morning cortisol
Answer: 3- Aldosterone:renin ratio
A 34-year-old man presents to the diabetes clinic with a history of thirst, polyuria and a recent 3.2 kg (7 lb) weight loss. His urine contains a small amount of ketones.
Which of the following would suggest he is most likely to have type-2 rather than type-1 diabetes?
1- A BMI of 23
2- High circulating insulin level
3- HLA type DR-3
4- Positive islet-cell antibodies
5- Plasma bicarbonate level of 8 mmol/l
Answer: 2- High circulating insulin level
A 54-year-old patient takes hydrocortisone 20mg in the mornings and 5mg at night for Addison’s disease. The endocrinology consultant would like her to take prednisolone instead. What dose of prednisolone should be started?
- 5 mg
- 7 mg
- 10 mg
- 20 mg
- 25 mg
Answer: 2- 7 mg
A 30-year-old woman presented with an 18-month history of polyuria and polydipsia. Her only other history of note was increasing joint pains, and one visit to the GP with depression some 6-months ago. Examination was unremarkable Bloods:
Glucose 4.1 mmol/l
Urea 7.2 mmol/l
Creatinine 80 micromol/l
Corrected serum calcium 3.1 mmol/l
Serum Phosphate 0.7 mmol/l
Parathyroid hormone 6.2 pmol/l (0.9-5.4)
Which of the following is the most likely cause of this clinical picture?
1- Raised levels of calcitonin
2- Hypervitaminosis D
3- Primary Hyperparathryoidism
4- Secondary Hyperparathryoidism
5- Medullary thyroid carcinoma
Answer: 3- Primary Hyperparathryoidism
A 31-year-old woman presents as her fingers intermittently turn white and become painful. She describes the fingers first turning white, then blue and finally red. This is generally worse in the winter months but it is present all year round. Wearing gloves does not help. Clinical examination of her hands, other joints and skin is unremarkable. Which one of the following treatments may be beneficial?
- Amitriptyline
- Aspirin
- Clopidogril
- Propranolol
- Nifedipine
Answer: 5- Nifedipine
A 54-year-old man who has received previous surgery for acromegaly is receiving lanreotide medical therapy as his growth hormone is persistently elevated.
What is the mode of action of lanreotide?
1- Inhibition of the somatostatin receptor
2- Inhibition of the growth hormone receptor
3- Stimulation of the somatostatin receptor
4- Stimulation of the dopamine D2 receptor
5- Inhibition of the dopamine D2 receptor
Answer: 3- Stimulation of the somatostatin receptor
A 41-year-old man with a past history of asthma presents with pain and weakness in his left hand. Examination findings are consistent with a left ulnar nerve palsy. Blood tests reveal an eosinophilia. Which one of the following gantibodies is most likely to be present?
- ANA
- Anti-Scl70
- pANCA
- cANCA
- Antiphospholipid antibodies
Answer: 3-pANCA
A 28-year-old woman attends the diabetes clinic with her two children. This is her third pregnancy and although not normally diabetic she was diagnosed with gestational diabetes mellitus. Recent fasting plasma glucose levels have been in the range of 5-6 mmol/l and she is taking bd mixed insulins. Later that evening she collapses while shopping and is brought to the Emergency Department with blood glucose of 2.4 mmol/l.
Which of the following represents the most appropriate management in this patient?
1- Reduce her dose of bd mixed insulin by 50%
2- Reduce her dose of bd mixed insulin by 20%
3- Check a random cortisol to rule out Addison’s disease
4- Change her to a basal bolus regime
5- Advise her to increase the size and regularity of her meals
Answer: 4- Change her to a basal bolus regime
A 32-year-old man presents with unilateral gynaecomastia. He had breast reduction surgery on the other side 10 yrs ago. On examination he has, sparse body hair in the axilla and pubic regions. Two testicles are identified, both of small volume. On further questioning you elucidate that he has a normal sense of smell. His blood tests reveal:
Testoterone 4nmol/l (9-35)
LH + FSH normal
Prolactin 400mU/l (<360)
Which of the following is the most likely diagnosis?
1- Klinefelter’s syndrome
2- Kallman’s syndrome
3- Androgen insensitivity
4- Testicular feminisation
5- 17-beta hydroxylase deficiency
Answer: 1- Klinefelter’s syndrome
A 27-year-old woman with type-1 diabetes mellitus attends for her routine review and says she is keen on becoming pregnant.
Which of the following is the factor most likely to make you ask her to defer pregnancy at this stage?
1- Minor background retinopathy
2- Hb A1C 9.4%
3- She hasn’t been taking folic acid
4- Microalbumin level of 6-mg excretion in 24 hours
5- Sensory neuropathy
Answer: 2- Hb A1C 9.4%
A 24-year-old woman is evaluated for worsening of her hand pain, myalgia and diffuse erythematous rash. This associated with fever and dry cough. She was diagnosed with systemic lupus erythematosus 2 years ago. She has been treated with hydroxychloroquine 100 mg twice/d and prednisone, 5 mg/d, & since the time of her diagnosis with good control of her symptoms. On physical examination, blood pressure: 130/92 mm Hg, pulse rate 99/ min., temperature is 37.8 C°, respiratory rate 12 / min. A malar rash is present. Mild erythema and effusion in the both wrist joints are noted, cardiac examination & chest examination is unremarkable. Lab. tests show the following: WBC: 3000 /mm³, Hb: 10.5 g/dl, platelets: 90.000/mm³, ESR: 60 mm/ hour, CRP: 3 mg/L, urea = 47 mg/dl, S. creatinin: 1.1 mg/dl.
- Stop the prednisolone send the patient for AFB in sputum
- Stop the prednisolone and start broad spectrum antibiotics intravenously bending
- Intravenous methylprednisolone 1 g daily for three consecutive days followed by prednisolone 1 mg/kg/day
- Increase the dose of prednisolone to 60 mg daily
- Add methotrexate
Answer: 4-Increase the dose of prednisolone to 60 mg daily
A 42-year-old woman presents to the Emergency Clinic with palpitations and shortness of breath. Recent thyroid function tests on the hospital computer reveal thyroid-stimulating hormone (TSH) of <0.05 mU/l and a markedly elevated T4. You arrange blood gas testing.
Which of the following findings would be most consistent with Grave’s disease?
1- Respiratory acidosis
2- Decreased pa(O2)
3- Increased pa(CO2)
4- Decreased pa(CO2)
5- Decreased pH
Answer: 4- Decreased pa(CO2)
A 21-year-old Medical Student presents with recurrent collapses. These have occurred on a number of occasions in association with stressful periods on the wards. Most recently she has been attached to the Emergency department and has suffered two collapses during cardiac arrests of patients on the unit. Her father has a history of Type 1 diabetes. You are on call with her overnight and she collapses again, you collect a blood sample.
Bloods;
Glucose 1.6 mmol/l
Insulin 1261 pmol/l
C-Peptide 20 pmol/l (<400)
Which of the following is the most likely diagnosis?
1- Insulinoma
2- Glucagonoma
3- Phaeochromocytoma
4- Illicit use of sulphonylureas
5- Illicit use of insulin
Answer: 5- Illicit use of insulin
A 45-year-old man presents to the clinic complaining of a lump in the neck which becomes particularly more prominent when she swallows. On examination there is a thyroid nodule at the base of the neck. Leukocyte screening of two other family members who suffered thyroid carcinoma has revealed the ret proto-oncogene.
Which type of thyroid carcinoma is linked to the ret-proto-oncogene?
1- Papillary thyroid carcinoma
2- Anaplastic thyroid carcinoma
3- Follicular thyroid carcinoma
4- Medullary thyroid carcinoma
5- Thyroid lymphoma
Answer: 4- Medullary thyroid carcinoma
A 62-year-old man is brought to the Emergency department with a grand-mal seizure. You are aware from his notes that he has undergone chemotherapy for small cell carcinoma of the bronchus a few months earlier. His wife tells you that he was drowsy and not himself for a day or two before the seizure.
On examination he is very drowsy but you can wake him up with stimulation. He is very thin with evidence of muscle and fat loss consistent with his carcinoma. Neurological examination reveals no focal signs.
Bloods on admission;
Na+ 123 mmol/l
K+ 4.0 mmol/l
Creatinine 100 μmol/l
Urea 3.5 mmol/l
Hb 11.1 g/dl
WCC 4.5 x 109/L
PLT 230 x 109/L
You suspect SIADH and fluid restrict him. Despite no evidence of him having taken in more fluids than documented his sodium deteriorates to 119 mmol/l the following day. His drowsiness has increased.
Which of the following represents the most appropriate management for him?
1- Continue fluid restriction
2- Start dexamethasone
3- Give normal saline 0.9%
4- Give normal saline 1.8%
5- Start demeclocycline
Answer: 5- Start demeclocycline
A 45-year-old builder is admitted to the Emergency room after falling of his ladder. Past history of note includes hypertension which is managed with ramipril 10mg daily. The Emergency scan reveals a 4cm right sided adrenal mass. His blood pressure in the Emergency room is 145/90 mmHg.
Blood results;
Hb 12.1 g/dl
WCC 6.2 x 109/L
PLT 232 x 109/L
Na+ 138 mmol/l
K+ 3.6 mmol/l
Creatinine 100 μmol/l
Which of the following would be most likely to reveal the underlying diagnosis?
1- 24hr Urinary catecholamines
2- Plasma renin/aldosterone
3- MIBG scan
4- MRI adrenals
5- Urinary sodium
Answer: 2- Plasma renin/aldosterone
A 19-year-old woman is admitted to the Emergency room after a collapse. She is found to be hypoglycaemic. You understand from colleagues who accompanied her in the ambulance that she collapsed at work, and this has happened at least 3 times in the past 2 months. There is no past medical history of note apart from the fact that her father is obese and was diagnosed with Type 2 diabetes some 7 years ago.
Bloods;
Hb 13.9 g/dl
WCC 5.6 x 109/L
PLT 231 x 109/L
Na+ 139 mmol/l
K+ 3.9 mmol/l
Creatinine 80 μmol/l
Glucose 2.4 mmol/l
Insulin 350 IU/l
C-Peptide 0.1 U/l
Which of the following is the most likely diagnosis?
1- Sulphonylurea abuse
2- Metformin abuse
3- Retroperitoneal tumour
4- Insulinoma
5- Insulin abuse
Answer: 5- Insulin abuse
A diabetic heavy goods vehicle (HGV) driver has been changed from oral medication to insulin.
What is the consequence for his driving licence?
1- Keep the licence
2- Suspension for 3 months
3- Suspension for 6 month
4- Suspension for 1 year
5- Loss of licence
Answer: 5- Loss of licence
A 78-year-old man is admitted to hospital with a left hemiparesis and altered consciousness. He is on aspirin 75 mg, bendrofluazide 2.5 mg, atorvastatin 10 mg and glibenclamide 15 mg daily. His wife says he has been unwell for a couple of days and has been off his food. She has still been giving him all his medication.
Which of the following tests is going to be most helpful in finding an immediately reversible cause for his symptoms?
1- Blood glucose level
2- CT brain scan
3- ECG
4- Serum creatinine level
5- Troponin level
Answer: 1- Blood glucose level
A 35-year-old woman comes to see you for a complete physical exam. She has experienced cold intolerance, weakness and constipation for 3 months. Her menses are regular but scanty. Her history is significant for hypertension and peptic ulcer disease and her family history includes hypertension and diabetes. The patient is married but has never been pregnant and takes cimetidine 400 mg at bedtime, sustained-release nifedipine 60 mg daily and docusate sodium 100 mg three times a day. Her pulse is 58 beats/minute with a blood pressure of 135/90 mm Hg. Her skin is dry and scaly and she has hung-up reflexes. The rest of her exam is normal and the following labs are obtained serum chemistries are normal except for a creatine kinase of 300 U/l (normal range, 26-140 U/l); CBC is normal, free thyroxine (T4) is 6.4 pmol/l (normal range, 10-22 pmol/l) and thyroid stimulating hormone (TSH) is 1.5 mIU (normal range, 0.3-5.0 mIU).
Which of the following is most likely to confirm the underlying cause?
1- Free tri-iodothyronine (T3)
2- Thyroid ultrasound scan
3- Thyroid uptake scan
4- Pituitary magnetic resonance imaging (MRI)
5- Antithyroid antibodies
Answer: 4- Pituitary magnetic resonance imaging (MRI)
