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

1. A 42-year-old motor mechanic was referred to the dermatologist with small cauliflower-like deposits on the points of his elbows. He was generally well, but on systemic enquiry, he described intermittent claudication. He had previously been hypertensive, and was taking thyroxine for primary hypothyroidism.
On examination, he was moderately obese. He had xanthelasmata on the upper eyelids of both eyes and tuberoeruptive xanthomata on both elbows, both knees and the nape of the neck.
Investigations:
serum alanine aminotransferase78 U/L (5-35)
fasting plasma glucose7.8 mmol/L (3.0-6.0)
serum urate0.48 mmol/L (0.23-0.46)
serum cholesterol13.4 mmol/L (<5.2)
serum LDL cholesterolnot measurable
serum HDL cholesterol0.90 mmol/L (>1.55)
fasting serum triglycerides9.32 mmol/L (0.45-1.69)
apolipoprotein E genotypehomozygous for apolipoprotein E2
What is the most likely diagnosis?

A) lipoprotein lipase deficiency
B) abetalipoproteinaemia
C) heterozygous familial hypercholesterolaemia
D) familial combined hyperlipidaemia
E) type III hyperlipidaemia (dysbetalipoproteinaemia)

2. A 33-year-old woman presented with tiredness, palpitations, weight loss and emotional
lability 9 weeks after the birth of her third child.
On examination, she had a sinus tachycardia, a fine tremor, slight lid retraction and a mild
diffuse non-tender goitre.
Investigations:
serum thyroid-stimulating hormone<0.01 mU/L (0.4-5.0)
serum free T434.3 pmol/L (10.0-22.0)
technetium-99m scan of thyroid (20-min uptake)<1% (0.4-3.0)
What is the most appropriate treatment?

A) carbimazole
B) potassium perchlorate
C) propranolol
D) aqueous iodine oral solution
E) propylthiouracil

3. 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) add metformin
B) bariatric surgery
C) add orlistat
D) add exenatide
E) titrate levothyroxine dosage

4. A 78-year-old man presented with confusion, lethargy and thirst. He had hypertension treated with lisinopril 20 mg daily.
On examination, he was dehydrated. His pulse was 110 beats per minute and his blood pressure was 84/40 mmHg. Urinalysis showed ketones 1+.
Investigations:
serum sodium155 mmol/L (137-144) serum potassium5.2 mmol/L (3.5-4.9) serum bicarbonate17 mmol/L (20-28) serum urea40.0 mmol/L (2.5-7.0)
serum creatinine358 umol/L (60-110) random plasma glucose78.0 mmol/L He was treated with sodium chloride 0.9%. After 8 hours' treatment, his urine output was
10 mL/h and his blood pressure was 121/50 mmHg. Investigations (after 8 hours' treatment): serum sodium151 mmol/L (137-144)
serum potassium4.9 mmol/L (3.5-4.9) serum bicarbonate18 mmol/L (20-28) serum urea39.0 mmol/L (2.5-7.0) serum creatinine347 umol/L (60-110)
random plasma glucose48.0 mmol/L
What is the most appropriate next step in management?

A) compound lactate solution (Hartmann's solution)
B) sodium chloride 0.9%
C) sodium chloride 0.18% and glucose 4%
D) sodium chloride 0.45%
E) sodium chloride 0.18% and glucose 5%

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

Solutions: