Endocrinology

Question 1

1. Balanitis
   A 60-year-old man visits his GP complaining of tiredness. He has noticed weight
   loss over the last six months and irritation of the tip of his penis which appears
   inflamed on examination. He mentions he has been visiting the toilet more often
   than usual and feeling thirsty. The most appropriate investigation would be:
   A. Oral glucose tolerance test
   B. Measurement of glycated haemoglobin
   C. Random plasma glucose test
   D. Water deprivation test
   E. Measurement of triglyceride levels

Answer 1

C

Question 2

2. Tiredness
   A 33-year-old obese woman complains of tiredness. She has recently given birth to
   a healthy baby boy and is enjoying being a mother. However, she is becoming more
   reliant on her partner for support as she always feels exhausted and often becomes
   depressed. The patient has a poor appetite and often does not finish her meals,
   despite this she has gained 5 kg in the last 2 weeks. The most likely diagnosis is:
   A. Postpartum depression
   B. Eating disorder
   C. Hyperthyroidism
   D. Hypothyroidism
   E. Occult malignancy

Answer 2

D

Question 3

3. Weight gain
   A 28-year-old woman has noticed a change in her appearance; most notably her
   clothes do not fit properly and are especially tight around the waist. Her face
   appears flushed and more rounded than usual, despite exercising regularly and
   eating healthily her weight has steadily increased over the last 3 weeks. On visiting
   her GP, he notices her blood pressure has increased since her last visit and she has
   bruises on her arm. She is especially worried about a brain tumour. The most
   appropriate investigation would be:
   A. Low-dose dexamethasone test
   B. High-dose dexamethasone test
   C. Urinary catecholamines
   D. Computed tomography (CT) scan
   E. Urinary free cortisol measurement

Answer 3

E

Question 4

4. Sleep apnoea
   A 49-year-old man presents with a history of difficulty sleeping. He reports feeling
   increasingly tired and general weakness which he attributes to his poor sleep
   pattern. Additionally, the patient has noticed he has gained weight and sweats very
   easily. On examination, the patient has coarse facial features. The most likely
   diagnosis is:
   A. Hyperthyroidism
   B. Cushing’s disease
   C. Acromegaly
   D. Hypothyroidism
   E. Diabetes

Answer 4

C

Question 5

5. Visual disturbance
   A 42-year-old woman presents with visual disturbances. She reports having double
   vision which was intermittent initially but has now become much more frequent.
   In addition, she becomes breathless very easily and experiences palpitations. On
   examination, raised, painless lesions are observed on the front of her shins and
   finger clubbing. The most likely diagnosis is:
   A. De Quervain’s thyroiditis
   B. Thyroid storm
   C. Phaeochromocytoma
   D. Graves’ disease
   E. Plummer’s disease

Answer 5

D

Question 6

6. Goitre
   A 16-year-old girl presents to her GP complaining of a swelling in her neck which
   she has noticed in the last 2 weeks. She has felt more irritable although this is often
   transient. On examination, a diffuse swelling is palpated with no bruit on
   auscultation. The most likely diagnosis is:
   A. Hyperthyroidism
   B. Simple goitre
   C. Riedel’s thyroiditis
   D. Thyroid carcinoma
   E. Thyroid cyst

Answer 6

B

Question 7

7. Dizziness
   A 22-year-old woman complains of dizziness and feeling light-headed. She works
   in an office and most frequently experiences this when standing up to visit the
   toilet. She has never fainted. The patient has lost 5 kg, but attributes this to eating
   more healthily. She has noticed a recent scar on the back of her hand which has
   started to turn very dark. The most appropriate investigation is:
   A. Synacthen test
   B. Low-dose dexamethasone test
   C. Cortisol measurement
   D. Urinary free cortisol measurement
   E. Abdominal ultrasound (US) scan

Answer 7

A

Question 8

8. Polyuria
   A 29-year-old man presents with a 4-week history of polyuria and extreme thirst.
   The patient denies difficulty voiding, hesitancy or haematuria, although the urine
   is very dilute. The patient does not believe he has lost any weight and maintains a
   good diet. No findings are found on urine dipstick. The most appropriate
   investigation is:
   A. Serum osmolality
   B. Fasting plasma glucose
   C. Urinary electrolytes
   D. Magnetic resonance imaging (MRI) scan of the head
   E. Water deprivation test

Answer 8

E

Question 9

9. Confusion (1)
   A 69-year-old man presents with confusion. His carers state that over the last month he has become increasingly lethargic, irritable and confused. Despite
   maintaining a good appetite, he has lost 10 kg in the last month. Blood results are
   as follows:
   Sodium 125 mmol/L
   Potassium 4 mmol/L
   Urea 3
   Glucose (fasting) 6 mmol/L
   Urine osmolality 343 mmol/L
   The most likely diagnosis is:
   A. Hypothyroidism
   B. Dilutional hyponatraemia
   C. Addison’s disease
   D. Acute tubulointerstitial nephritis
   E. Syndrome of inappropriate anti-diuretic hormone (SIADH)

Answer 9

E

Question 10

10. Stridor
    A 54-year-old woman presents to her GP complaining of a change in her breathing
    sound. She first noticed numbness, particularly in her fingers and toes, three
    months ago but attributed this to the cold weather. Her partner now reports hearing
    a high pitched, harsh sound while she is sleeping. Her BMI is 27. While measuring
    blood pressure, you notice the patient’s wrist flexing. The most likely diagnosis is:
    A. Obstructive sleep apnoea
    B. Hypocalcaemia
    C. DiGeorge syndrome
    D. Guillain–Barré syndrome
    E. Raynaud’s syndrome

Answer 10

B

Question 11

11. Depression
    A 39-year-old man presents with a three-month history of depression. The patient
    recently lost a family member and around the same period began to feel unwell
    with constipation and a depressed mood. He has started taking analgesia for a
    sharp pain in his right lower back that often radiates towards his front. The most
    appropriate investigation is:
    A. Serum parathyroid hormone
    B. Serum thyroid stimulating hormone
    C. Colonoscopy
    D. Fasting serum calcium
    E. MRI scan

Answer 11

D

Question 12

12. High blood pressure
    A 47-year-old woman presents to clinic after being referred from her GP for
    consistently elevated blood pressure. Her last reading was 147/93. The female does
    not report any symptoms but recently lost her job and attributes the elevated
    reading to stress. Her blood tests are as follows:
    Sodium 146
    Potassium 3.4
    Glucose (random) 7.7
    Urea 4
    The most appropriate investigation is:
    A. CT scan
    B. 24-hour ambulatory blood pressure
    C. Abdominal ultrasound scan
    D. Aldosterone–renin ratio
    E. Glucose tolerance test

Answer 12

B

Question 13

13. Panic attack
    A 65-year-old woman complains of panic attacks. She has recently retired as a
    school teacher, but 2–3 times a week she suffers extreme anxiety, becomes short of
    breath and sweats excessively. Elevated catecholamines are detected in the urine.
    The most appropriate medical treatment is:
    A. Phenoxybenzamine alone
    B. Prolopanolol alone
    C. Phenoxybenzamine followed by propanolol
    D. Sodium nitroprusside
    E. Propanolol followed by phenoxybenzamine

Answer 13

C

Question 14

14. Weight loss
    A 47-year-old woman complains of weight loss. She has a family history of type 1
    and type 2 diabetes but has never been diagnosed herself despite the finding of islet
    cell antibodies. In the last few months, however, she has noticed progressively
    increasing polyuria and poydipsia and 5 kg of weight loss. Her fasting plasma
    glucose is 8 mmol/L and urine dipstick shows the presence of ketones. The most
    likely diagnosis is:
    A. Type 1 diabetes
    B. Non-ketotic hyperosmolar state
    C. Type 2 diabetes
    D. Occult malignancy
    E. Latent autoimmune diabetes of adults (LADA)

Answer 14

E

Question 15

15. Diabetes management (1)
    A 50-year-old Asian man is referred to the diabetes clinic after presenting with
    polyuria and polydipsia. He has a BMI of 30, a blood pressure measurement of
    137/88 and a fasting plasma glucose of 7.7 mmol/L. The most appropriate first-line
    treatment is:
    A. Dietary advice and exercise
    B. Sulphonylurea
    C. Exenatide
    D. Thiazolidinediones
    E. Metformin

Answer 15

A

Question 16

16. Neuropathy
    A 55-year-old diabetic woman presents with altered sensations in her hands and
    feet. She finds it difficult to turn pages of books and discriminating between
    different coins. When walking, the floor feels different and she likens the sensation
    to walking on cotton wool. The most likely diagnosis is:
    A. Autonomic neuropathy
    B. Diabetic amyotrophy
    C. Acute painful neuropathy
    D. Symmetrical sensory neuropathy
    E. Diabetic mononeuropathy

Answer 16

D

Question 17

17. Abdominal lump
    A 29-year-old woman is referred to a diabetic clinic for poor diabetes management.
    She was diagnosed with type 1 diabetes at the age of 12 and prescribed actrapid
    insulin injections. Recently, the patient has been suffering fluctuations in her
    plasma glucose levels and her previously well-controlled glycated haemoglobin has
    risen to 8.1 per cent. The patient admits she has recently been avoiding using her
    injections. On examination, the patient has a raised, smooth lump that is firm on
    palpation at the lower abdomen. The most likely diagnosis is:
    A. Worsening of diabetes
    B. Lipohypertrophy
    C. Injection scarring
    D. Lipoma
    E. Injection abscess

Answer 17

B

Question 18

18. Headache
    A 15-year-old girl complains of headaches which started 6 weeks ago. The
    headaches initially occurred 1–2 times a week but now occur up to five times a
    week, they are not associated with any neurological problems, visual disturbances,
    nausea or vomiting. The girl also reports a white discharge from both of her nipples.
    She has not started menstruating. The most appropriate investigation is:
    A. Lateral skull x-ray
    B. CT scan
    C. MRI scan
    D. Thyroid function tests
    E. Serum prolactin measurement

Answer 18

E

Question 19

19. Striae
    A 7-year-old girl presents with red striae which her mother noticed around her
    abdomen. The girl also has plethoric cheeks and, on her back, several faint, irregular
    brown macules are observed. The mother is particularly concerned about the early
    breast development that seems apparent on her daughter. Serum phosphate is
    decreased. The most likely diagnosis is:
    A. Paget’s disease of the bone
    B. McCune–Albright syndrome
    C. Cushing’s disease
    D. Hypopituitarism
    E. Neurofibromatosis

Answer 19

B

Question 20

20. Delayed puberty
    An 18-year-old man presents to clinic worried about his scant pubic hair
    development. Examination reveals undescended testes and plasma testosterone,
    luteinizing hormone and follicle stimulating hormone were found to be low. A
    karytotype test was 46, XY. The patient was otherwise well, but during neurological
    examination struggled during the olfactory test. The most likely diagnosis is:
    A. Hypogonadotropic hypogonadism
    B. Klinefelter’s disease
    C. Androgen insensitivity syndrome
    D. 5-alpha reductase deficiency
    E. Kallman’s syndrome

Answer 20

E

Question 21

21. Room temperature intolerance
    A 47-year-old woman is referred to the endocrine clinic complaining of a twomonth
    history of tiredness. Despite wearing several items of clothing, the patient
    appears intolerant to the room temperature. She has noticed an increase in weight,
    particularly around her waist. The most appropriate investigation is:
    A. Radioiodine scan
    B. Thyroid stimulating hormone (TSH)
    C. Total tetraiodothyronine level (T4)
    D. Tri-iodothyronine level (T3)
    E. Ultrasound scan of the neck

Answer 21

B

Question 22

22. Painful neck
    A 58-year-old woman presents with an acutely painful neck, the patient has a
    fever, blood pressure is 135/85 mmHg and heart rate 102 bpm. The patient explains
    the pain started 2 weeks ago and has gradually become worse. She also notes
    palpitations particularly and believes she has lost weight. The symptoms subside
    and the patient presents again complaining of intolerance to the cold temperatures.
    The most likely diagnosis is:
    A. Thyroid papillary carcinoma
    B. Plummer’s disease
    C. De Quervain’s thyroiditis
    D. Hyperthyroidism
    E. Thyroid follicular carcinoma

Answer 22

C

Question 23

23. Abdominal pain
    A 6-year-old girl presents to accident and emergency with severe abdominal pain,
    nausea and vomiting. On examination, the patient is tachypnoeic, capillary refill is
    3 seconds and she has a dry tongue. While listening to the patient’s lungs, you
    detect a sweet odour from her breath. The most likely diagnosis is:
    A. Diabetic ketoacidosis
    B. Non-ketotic hyperosmolar state
    C. Gastroenteritis
    D. Pancreatitis
    E. Adrenal crisis

Answer 23

A

Question 24

24. Bilateral adrenalectomy complication
    A 45-year-old Asian man is diagnosed with Cushing’s disease in India. He undergoes
    a bilateral adrenalectomy and recovers well from the operation. On his return to the
    UK one year later, he complains of a constant dull headache, peripheral visual
    disturbances and increasing pigmentation of the skin creases of both hands. The
    most likely diagnosis is:
    A. Ectopic ACTH secreting tumour
    B. Prolactinoma
    C. Nelson syndrome
    D. Addison’s disease
    E. Side effects from iatrogenic steroid intake

Answer 24

C

Question 25

25. Loss of consciousness
    A 29-year-old woman is found unconscious by her partner and rushed to accident
    and emergency. She is a type 1 diabetic and has maintained excellent glucose
    control using insulin injections. Blood biochemistry results demonstrate a
    moderately raised level of insulin, no detectable C-peptide and very low blood
    glucose. Her partner mentions she is a lawyer and has been working particularly
    hard in the last week, eating quick meals and occasionally missing meals. The most
    likely diagnosis is:
    A. Hyperosmolar coma
    B. Diabetic ketoacidosis
    C. Insulin overdose
    D. Hypoglycaemic coma
    E. Autonomic neuropathy

Answer 25

D

Question 26

26. Diabetes management (2)
    A 49-year-old man has recently been diagnosed with type 2 diabetes and is being
    carefully monitored. He has been advised to maintain a healthier diet and lifestyle,
    he attends a follow-up clinic and claims to have been following the diet stringently
    since his last appointment three months ago. The most appropriate investigation is:
    A. Random plasma glucose
    B. Fasting plasma glucose
    C. Urine dipstick
    D. Glycated haemoglobin
    E. Weight measurement

Answer 26

D

Question 27

27. Diabetes treatment
    A 41-year-old man has been recently diagnosed with type 2 diabetes and has been
    following a plan of lifestyle measures to improve his diet and increase his level of
    exercise. On returning to clinic, his BMI is 23, fasting plasma glucose 9.0 mmol/L,
    blood pressure 133/84 mmHg and HbA1c of 7.1 per cent. The most appropriate
    treatment option is:
    A. Metformin
    B. Sulphonylurea
    C. Insulin
    D. Exenatide
    E. Further diet and exercise

Answer 27

B

Question 28

28. Parasthesia
    A 33-year-old man complains of a tingling sensation in his hands for several
    months which occasionally awakens him during sleep. The patient has noticed he
    has gained weight and no longer wears his wedding ring as it has become too tight.
    You notice the patient is sweating while speaking to you and has quite a large jaw,
    furrowed tongue and large hands. His blood pressure reading is 142/91 mmHg. The
    most appropriate investigation would be:
    A. MRI scan of the pituitary
    B. Glucose tolerance test
    C. Growth hormone levels
    D. Thyroid function tests
    E. Serum prolactin levels

Answer 28

B

Question 29

29. Prognathism
    A 19-year-old woman presents with concerns about changes to her facial
    appearance, in particular her nose and jaw seem quite large, she is also quite sweaty
    and despite using antiperspirants is finding it difficult to control and is afraid of
    embarrassment at university. A glucose tolerance test is performed and found to be
    raised. The most appropriate management would be:
    A. Trans-sphenoidal surgery
    B. Octreotide
    C. Bromocriptine
    D. Pituitary radiotherapy
    E. Pegvisomant

Answer 29

A

Question 30

30. Impaired fasting glucose
    A 29-year-old man presents to his GP complaining of being constantly thirsty, tired
    and visiting the toilet more often than usual during the last 4 days. He has noticed
    his clothes have become more baggy and he now needs to tighten his belt. His
    parents both have diabetes requiring insulin therapy. A fasting plasma glucose
    result is most likely to be:
    A. 9.0 mmol/L
    B. 6.0 mmol/L
    C. 16.3 mmol/L
    D. 5.0 mmol/L
    E. 3.0 mmol/L

Answer 30

C

Question 31

31. Ketonuria
    A 22-year-old woman is found unconscious in her room by her boyfriend and
    brought into accident and emergency. A urine dipstick is positive for glucose and
    ketones and blood analysis shows the following results:
    pH 6.9
    PCO2 3.0 kPa
    PO2 13 kPa
    Sodium 144 mmol/L
    Potassium 5.0 mmol/L
    Urea 11
    Glucose 20
    Chloride 100
    Bicarbonate 2.9
    The most likely anion gap is:
    A. 180
    B. 118
    C. 139.2
    D. 46.1
    E. 28

Answer 31

D

Question 32

32. Quadrantanopia
    A 37-year-old man presents with symptoms of an acute headache, vomiting,
    malaise and visual disturbance. A neurological examination reveals a bitemporal
    superior quadrantanopia. A CT scan shows a hyperdense area within the pituitary
    gland. The most likely diagnosis is:
    A. Kallman syndrome
    B. Septo-optic dysplasia
    C. Sheehan’s syndrome
    D. Empty sella syndrome
    E. Pituitary apoplexy

Answer 32

E

Question 33

33. Facial plethora
    A 38-year-old woman presents to clinic complaining of changes in her appearance
    and weight gain. She has recently been through a divorce and attributed her weight
    gain to this. However, despite going to the gym her clothes are still tight, especially
    around her waist, her face seems puffy and flushed. The most likely diagnosis is:
    A. Hyperthyroidism
    B. Cushing’s disease
    C. Acromegaly
    D. Hypothyroidism
    E. Diabetes

Answer 33

C

Question 34

34. Collapse
    A 60-year-old diabetic man recovering from sepsis after collapsing at home was
    treated with appropriate antibiotics after blood culture and aggressive fluid
    management with 0.9 per cent saline for 2 days for hypotension. Although blood
    pressure returned to normal, the patient had the following abnormal biochemical
    blood results:
    pH 7.32
    PCO2 5.2
    PO2 11.1
    Sodium 147 mmol/L
    Potassium 3.5 mmol/L
    Chloride 119 mmol/L
    Bicarbonate 19.5
    The most likely diagnosis is:
    A. Diabetic ketoacidosis
    B. Lactic acidosis
    C. Conn’s syndrome
    D. Renal tubular acidosis type 1
    E. Hyperchloremic acidosis

Answer 34

E

Question 35

35. Confusion
    A 57-year-old woman, who has recently returned from a holiday in America,
    presents with dull grey-brown patches in her mouth and the palms of her hand
    which she has noticed in the last week. She has also noticed she gets very dizzy
    when rising from a seated position and is continually afraid of fainting. The most
    likely diagnosis is:
    A. Addison’s disease
    B. SIADH
    C. Conn’s syndrome
    D. Waterhouse–Friderichsen syndrome
    E. 17-hydroxylase deficiency

Answer 35

A