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

2. A 32-year-old man presented with persistent thirst. He had a past history of polydactyly, which had been corrected surgically in infancy. His family had remarked about his recent weight gain. His only concern was of blurring of vision and difficulty reading. His father and paternal grandfather had each developed type 2 diabetes mellitus when aged 41 and 56 years, respectively.
His body mass index was 34 kg/m2 (18-25). Urinalysis showed glucose 2+, ketones 1+.
Investigations:
serum sodium142 mmol/L (137-144)
serum potassium3.8 mmol/L (3.5-4.9)
serum chloride105 mmol/L (95-107)
serum urea5.0 mmol/L (2.5-7.0)
serum creatinine90 umol/L (60-110)
haemoglobin A1c91 mmol/mol (20-42)
random plasma glucose11.3 mmol/L
ultrasound scan of kidneysnormal
What is the most likely underlying diagnosis?

A) monogenic diabetes caused by a mutation in the HNF-1? gene
B) Bardet-Biedl syndrome
C) monogenic diabetes caused by a mutation in the glucokinase gene
D) Prader-Willi syndrome
E) type 2 diabetes mellitus

3. A 64-year-old woman presented with features of acromegaly. An MR scan showed a pituitary tumour with cavernous sinus extension. She underwent trans-sphenoidal surgery and histology of the pituitary tissue showed numerous cells immunostaining for growth hormone.
Investigations (6 months postoperatively):
MR scan of pituitaryenlarged sella, residual tumour in right cavernous sinus
serum growth hormone (day curve average)3.2 ?g/L (<2)
serum insulin-like growth factor 142.0 nmol/L (3.3-23.3)
What is the most appropriate next step in management?

A) watchful waiting
B) repeat trans-sphenoidal surgery
C) pegvisomant
D) long-acting octreotide
E) conventional external beam radiotherapy to pituitary region

4. A 24-year-old woman was referred with an 18-month history of worsening hirsutism, primarily on her face, but also new hair growth on her chest. She was shaving weekly. She had always been overweight, but had recently gained 5 kg and her body mass index was 31 kg/m2 (18-25). Her periods were regular.
What is the most relevant next investigation?

A) plasma thyroid-stimulating hormone
B) overnight dexamethasone suppression test (after 1 mg dexamethasone)
C) serum testosterone
D) serum 17-hydroxyprogesterone
E) serum dehydroepiandrosterone

5. An 18-year-old man presented with delayed puberty.
On examination, he had a high arched palate. His sense of smell was intact, and he had a
family history of pubertal delay. Kallman's syndrome was suspected.
Investigations:
serum testosterone0.3 nmol/L (9.0-35.0)
serum follicle-stimulating hormone1.0 U/L (1.0-7.0)
serum luteinising hormone1.0 U/L (1.0-10.0)
bone age15 years
What further clinical finding would most strongly support the diagnosis of Kallman's
syndrome?

A) eunuchoid habitus
B) short stature
C) night blindness
D) testes 6 mL bilaterally
E) bimanual synkinesia (mirror movements)

Solutions: