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

1. A 50-year-old Asian woman with an 18-year history of type 2 diabetes mellitus complained of discomfort and mild swelling in her left foot after tripping on a pavement. She was being treated with metformin, gliclazide and pioglitazone.
On examination, her foot was warm and slightly oedematous over the dorsum but not discoloured. She was afebrile and the foot pulses were bounding. Tendon reflexes in the legs were absent and vibration perception diminished. Urinalysis showed protein 2+, glucose 1+.
Investigations:
white cell count5.2 ? 109/L (4.0-11.0)
serum creatinine140 umol/L (60-110)
haemoglobin A1c63 mmol/mol (20-42)
X-ray of left footnormal bone architecture; some calcification of the arteries
isotope bone scanincreased isotope uptake in the mid-foot only
What is the most effective next step in management?

A) celecoxib
B) alendronic acid
C) co-amoxiclav
D) below-knee removable walking boot
E) immobilisation in a cast

2. A 23-year-old barmaid presented with headache, sweating and collapse. She had a past medical history of tension headache and unexplained abdominal pain. Her regular medication included amitriptyline 25 mg at night and paracetamol 1 g as required. She was a smoker and regularly drank alcohol.
On examination, her pulse was 120 beats per minute and her blood pressure was 210/128 mmHg.
Investigations:
24-h urinary metanephrine5.4 umol (<2)
24-h urinary normetanephrine15.2 umol (<3) What substance is most likely to cause assay interference in the measurement of urinary metanephrines?

A) paracetamol
B) caffeine
C) nicotine
D) alcohol
E) amitriptyline

3. A 59-year-old man with an 8-year history of type 2 diabetes mellitus was seen in the outpatient clinic. He had worsening renal function in the absence of microalbuminuria.
On examination, his blood pressure was 175/90 mmHg. He had a femoral bruit, and absent dorsalis pedis pulses bilaterally.
Investigations:
serum creatinine150 umol/L (60-110)
estimated glomerular filtration rate (MDRD)39 mL/min/1.73m2 (>60)
In addition to addressing his blood pressure, what is the most appropriate next investigation?

A) MR angiography of renal arteries
B) renal ultrasound scan with Doppler studies
C) captopril diethylene triamine pentacaetic acid (DTPA) scan
D) mercaptoacetyltriglycine (MAG3) renography
E) lower limb angiography

4. A 23-year-old man presented with a history of discomfort with his gender for as long as he could remember. He believed he was transsexual.
What element of further history would most strongly support his self-diagnosis?

A) a long-standing intense wish to make his body conform to that of the preferred gender
B) the presence of gender somatic delusions that emerge and strengthen with time
C) conscious and absolute rejection of his sexual orientation as socially unacceptable
D) sexual excitement by cross-dressing
E) seeking medical rationalisation for sexuality through genital surgery

5. A 58-year-old man was referred to the endocrine clinic after a CT scan of abdomen had shown a 4.5-cm left adrenal mass, with a Hounsfield unit measurement of 11 (consistent with high lipid content). He had a 10-year history of type 2 diabetes mellitus and was taking metformin. He was also taking atenolol for hypertension.
On examination at the clinic, his blood pressure was 162/94 mmHg. He was centrally obese with a body mass index of 27 kg/m2 (18-25).
Investigations:
serum potassium3.9 mmol/L (3.5-4.9)
plasma renin activity (after 30 min upright)1.0 pmol/mL/h (3.0-4.3)
plasma aldosterone (after 4 h upright)680 pmol/L (330-830)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol164 nmol/L (<50)
24-h urinary free cortisol132 nmol (55-250)
24-h urinary catecholamines
(adrenaline and noradrenaline)normal
As the lesion was >4 cm in diameter, laparoscopic adrenalectomy was recommended.
What is the most appropriate advice to give to the surgical team about perioperative
management?

A) give preoperative ?-adrenergic receptor blockade in case the lesion is an occult phaeochromocytoma
B) short tetracosactide (Synacthen@) test 48 h postoperatively
C) give corticosteroid cover during and after surgery and reassess postoperatively
D) measure cortisol and aldosterone 2 weeks postoperatively
E) no special precautions are required

Solutions: