QUESTION NO: 1
A 33-year-old woman was reviewed in the insulin pump clinic. She had had type 1 diabetes mellitus for 10 years. She had been treated with a continuous subcutaneous insulin infusion 3 years previously, because of frequent hypoglycaemic episodes. She had recently undergone continuous glucose monitoring (see image).
Investigations:
haemoglobin A1c43 mmol/mol (20-42)
What is the most likely cause of the blood glucose trace seen between 08.00 h and 10.00 h?
A 33-year-old woman was reviewed in the insulin pump clinic. She had had type 1 diabetes mellitus for 10 years. She had been treated with a continuous subcutaneous insulin infusion 3 years previously, because of frequent hypoglycaemic episodes. She had recently undergone continuous glucose monitoring (see image).
Investigations:
haemoglobin A1c43 mmol/mol (20-42)
What is the most likely cause of the blood glucose trace seen between 08.00 h and 10.00 h?
Correct Answer: A
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QUESTION NO: 2
A 23-year-old woman presented to the outpatient clinic complaining of an inability to lose weight and irregular menses. Her food diary suggested that she consumed only 900 kilocalories daily. She had previously been found to have hypothyroidism and was treated with levothyroxine 75 micrograms daily.
On examination, her body mass index was 40.2 kg/m2 (18-25).
Investigations:
serum testosterone3.6 nmol/L (0.5-3.0) plasma follicle-stimulating hormone3.0 U/L (2.5-10.0) plasma luteinising hormone9.0 U/L (2.5-10.0) serum thyroid-stimulating hormone4.6 mU/L (0.4-5.0) serum free T412.8 pmol/L (10.0-22.0)
What is the most appropriate next step?
A 23-year-old woman presented to the outpatient clinic complaining of an inability to lose weight and irregular menses. Her food diary suggested that she consumed only 900 kilocalories daily. She had previously been found to have hypothyroidism and was treated with levothyroxine 75 micrograms daily.
On examination, her body mass index was 40.2 kg/m2 (18-25).
Investigations:
serum testosterone3.6 nmol/L (0.5-3.0) plasma follicle-stimulating hormone3.0 U/L (2.5-10.0) plasma luteinising hormone9.0 U/L (2.5-10.0) serum thyroid-stimulating hormone4.6 mU/L (0.4-5.0) serum free T412.8 pmol/L (10.0-22.0)
What is the most appropriate next step?
Correct Answer: A
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QUESTION NO: 3
A 55-year-old woman presented with a 3-week history of nausea and vomiting. Her only medical complaints were frequent dyspepsia, for which she was taking indigestion tablets, and asthma for which she was taking a salbutamol inhaler as required.
On examination, there was no evidence of lymphadenopathy, her chest was clear on auscultation and abdominal examination was normal.
Investigations (before and after taking omeprazole for 3 weeks):
beforeafternormal erythrocyte sedimentation rate (mm/1st h)44<30 serum creatinine (umol/L)17011060-110 serum corrected calcium (mmol/L)2.852.402.20-2.60
serum phosphate (mmol/L)1.90.8-1.4
serum angiotensin-converting enzyme (U/L)8525-82
plasma parathyroid hormone (pmol/L)0.44.40.9-5.4
What is the most likely cause of the hypercalcaemia?
A 55-year-old woman presented with a 3-week history of nausea and vomiting. Her only medical complaints were frequent dyspepsia, for which she was taking indigestion tablets, and asthma for which she was taking a salbutamol inhaler as required.
On examination, there was no evidence of lymphadenopathy, her chest was clear on auscultation and abdominal examination was normal.
Investigations (before and after taking omeprazole for 3 weeks):
beforeafternormal erythrocyte sedimentation rate (mm/1st h)44<30 serum creatinine (umol/L)17011060-110 serum corrected calcium (mmol/L)2.852.402.20-2.60
serum phosphate (mmol/L)1.90.8-1.4
serum angiotensin-converting enzyme (U/L)8525-82
plasma parathyroid hormone (pmol/L)0.44.40.9-5.4
What is the most likely cause of the hypercalcaemia?
Correct Answer: D
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QUESTION NO: 4
A 27-year-old woman with type 1 diabetes mellitus was invited to attend a structured education (e.g. DAFNE) coursE.
Which quality of life domain is most affected when a person is found to have type 1 diabetes mellitus?
A 27-year-old woman with type 1 diabetes mellitus was invited to attend a structured education (e.g. DAFNE) coursE.
Which quality of life domain is most affected when a person is found to have type 1 diabetes mellitus?
Correct Answer: D
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QUESTION NO: 5
A 55-year-old male-to-female transsexual was reviewed in clinic. She lived as a woman but had not undergone gender reassignment surgery. She was treated with cyproterone acetate 50 mg twice daily and estradiol 2 mg twice daily.
What are the most important tests for monitoring safe replacement?
A 55-year-old male-to-female transsexual was reviewed in clinic. She lived as a woman but had not undergone gender reassignment surgery. She was treated with cyproterone acetate 50 mg twice daily and estradiol 2 mg twice daily.
What are the most important tests for monitoring safe replacement?
Correct Answer: C
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QUESTION NO: 6
A 46-year-old Afro-Caribbean man with sarcoidosis was found to have hypercalcaemia and was treated with prednisolone 20 mg/day. Within 3 weeks his serum calcium had fallen to within the reference range.
How do glucocorticoids reduce serum calcium in sarcoidosis?
A 46-year-old Afro-Caribbean man with sarcoidosis was found to have hypercalcaemia and was treated with prednisolone 20 mg/day. Within 3 weeks his serum calcium had fallen to within the reference range.
How do glucocorticoids reduce serum calcium in sarcoidosis?
Correct Answer: D
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QUESTION NO: 7
A 36-year-old man of South Asian origin presented acutely with a widespread pruritic rash involving the extensor surfaces of the limbs.
On examination, he was moderately obese with a body mass index of 33 kg/m2 (18-25), and the rash was erythematous, with multiple small papules with yellow centres.
Investigations:
fasting plasma glucose11.0 mmol/L (3.0-6.0)
haemoglobin A1c109 mmol/mol (20-42)
serum cholesterol8.0 mmol/L (<5.2)
serum HDL cholesterol0.80 mmol/L (>1.55)
fasting serum triglycerides31.00 mmol/L (0.45-1.69)
What is the most likely diagnosis?
A 36-year-old man of South Asian origin presented acutely with a widespread pruritic rash involving the extensor surfaces of the limbs.
On examination, he was moderately obese with a body mass index of 33 kg/m2 (18-25), and the rash was erythematous, with multiple small papules with yellow centres.
Investigations:
fasting plasma glucose11.0 mmol/L (3.0-6.0)
haemoglobin A1c109 mmol/mol (20-42)
serum cholesterol8.0 mmol/L (<5.2)
serum HDL cholesterol0.80 mmol/L (>1.55)
fasting serum triglycerides31.00 mmol/L (0.45-1.69)
What is the most likely diagnosis?
Correct Answer: B
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QUESTION NO: 8
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 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?
Correct Answer: D
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QUESTION NO: 9
A 24-year-old woman presented with a 1-year history of secondary amenorrhoea. She also complained of milky discharge from her breasts. She was otherwise well, but had been having difficulty getting pregnant despite regular sexual intercourse. She was taking no medication.
Investigations:
serum prolactin3214 mU/L (<360)
serum thyroid-stimulating hormone2.4 mU/L (0.4-5.0)
serum free T415.6 pmol/L (10.0-22.0)
MR scan of pituitary7-mm left-sided pituitary mass
with no extension beyond the sella
What is the most appropriate licensed therapy in the UK to assist conception?
A 24-year-old woman presented with a 1-year history of secondary amenorrhoea. She also complained of milky discharge from her breasts. She was otherwise well, but had been having difficulty getting pregnant despite regular sexual intercourse. She was taking no medication.
Investigations:
serum prolactin3214 mU/L (<360)
serum thyroid-stimulating hormone2.4 mU/L (0.4-5.0)
serum free T415.6 pmol/L (10.0-22.0)
MR scan of pituitary7-mm left-sided pituitary mass
with no extension beyond the sella
What is the most appropriate licensed therapy in the UK to assist conception?
Correct Answer: E
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QUESTION NO: 10
A 34-year-old woman presented with palpitations, heat intolerance and a slight tremor. She was 9 weeks into her first pregnancy. She had not had any morning sickness.
On examination, her pulse was 100 beats per minute. She had a small uniform goitre but no tremor and no eye signs.
Investigations:
serum thyroid-stimulating hormone<0.01 mU/L (0.4-5.0)
serum free T442.0 pmol/L (10.0-22.0)
serum free T315.0 pmol/L (3.0-7.0)
anti-thyroid-stimulating hormone receptor
antibodies14 U/L (<7)
The decision was taken to treat her Graves' disease with propylthiouracil (PTU) rather than carbimazole.
What is the reason for this decision?
A 34-year-old woman presented with palpitations, heat intolerance and a slight tremor. She was 9 weeks into her first pregnancy. She had not had any morning sickness.
On examination, her pulse was 100 beats per minute. She had a small uniform goitre but no tremor and no eye signs.
Investigations:
serum thyroid-stimulating hormone<0.01 mU/L (0.4-5.0)
serum free T442.0 pmol/L (10.0-22.0)
serum free T315.0 pmol/L (3.0-7.0)
anti-thyroid-stimulating hormone receptor
antibodies14 U/L (<7)
The decision was taken to treat her Graves' disease with propylthiouracil (PTU) rather than carbimazole.
What is the reason for this decision?
Correct Answer: A
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QUESTION NO: 11
An 18-year-old man, whose ambition was to become a member of the elite armed forces, presented with gynaecomastia. His weekly alcohol consumption was 35 units.
On examination, he had normal secondary sexual characteristics, a well-developed, muscular physique and modest, slightly tender bilateral gynaecomastia. Testes were 10 mL with soft texture.
Investigations:
haemoglobin160 g/L (130-180)
MCV96 fL (80-96)
serum dehydroepiandrosterone sulphate4 umol/L (2-10)
serum oestradiol180 pmol/L (<180)
serum testosterone (09.00 h)6.0 nmol/L (9.0-35.0)
plasma follicle-stimulating hormone1.0 U/L (1.0-7.0)
plasma luteinising hormone0.7 U/L (1.0-10.0)
serum prolactin420 mU/L (<360)
What is the most likely diagnosis?
An 18-year-old man, whose ambition was to become a member of the elite armed forces, presented with gynaecomastia. His weekly alcohol consumption was 35 units.
On examination, he had normal secondary sexual characteristics, a well-developed, muscular physique and modest, slightly tender bilateral gynaecomastia. Testes were 10 mL with soft texture.
Investigations:
haemoglobin160 g/L (130-180)
MCV96 fL (80-96)
serum dehydroepiandrosterone sulphate4 umol/L (2-10)
serum oestradiol180 pmol/L (<180)
serum testosterone (09.00 h)6.0 nmol/L (9.0-35.0)
plasma follicle-stimulating hormone1.0 U/L (1.0-7.0)
plasma luteinising hormone0.7 U/L (1.0-10.0)
serum prolactin420 mU/L (<360)
What is the most likely diagnosis?
Correct Answer: A
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