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MRCPUK SEND Exam Syllabus Topics:

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

1. A 26-year-old woman was recovering from diabetic ketoacidosis and had been switched to her usual basal bolus insulin regimen. Her capillary blood glucose measurements during the day were high but fasting plasma glucose was in the range 5.0-7.0 mmol/L (3.0-6.0). She was drinking and eating normally.
On examination, her pulse was 76 beats per minute and her blood pressure was 106/66 mmHg. Urinalysis showed ketones 1+.
Investigations:
serum sodium143 mmol/L (137-144)
serum potassium4.4 mmol/L (3.5-4.9)
serum bicarbonate22 mmol/L (20-28)
serum creatinine72 umol/L (60-110)
plasma glucose 2 h after breakfast21 mmol/L
What is the most appropriate next step in management?

A) start variable-rate intravenous insulin infusion
B) change to twice daily pre-mixed insulin
C) increase bolus insulin with meal
D) start glucose 5% with intravenous insulin
E) increase basal insulin at bed time

2. A 28-year-old man was seen in the lipid clinic following a referral from the general surgical team. He had had two episodes of acute pancreatitis over the preceding 6 months, which settled spontaneously. He had a past medical history of HIV disease and was taking highly active antiretroviral (HAART) therapy. He drank 12 units of alcohol per week.
On examination, he had no stigmata of hyperlipidaemia.
Investigations:
fasting plasma glucose6.2 mmol/L (3.0-6.0)
haemoglobin A1c44 mmol/mol (20-42)
serum cholesterol7.5 mmol/L (<5.2)
fasting serum triglycerides23.70 mmol/L (0.45-1.69)
serum thyroid-stimulating hormone0.7 mU/L (0.4-5.0)
serum free T414.3 pmol/L (10.0-22.0)
What class of antiretroviral drug is the most likely cause of his metabolic disturbance?

A) integrase inhibitors (e.g. raltegravir)
B) nucleoside reverse transcriptase inhibitors (e.g. zidovudine)
C) protease inhibitors (e.g. ritonavir)
D) non-nucleoside reverse transcriptase inhibitors (e.g. nevirapine)
E) entry inhibitors (e.g. enfuvirtide)

3. A 16-year-old boy was referred with concern about delayed puberty. His stature had been short as a child. He reported an increase in height at the age of 13, and had begun to develop pubic hair at the age of 14. He reported no further growth or development in the past year. His father recalled going through puberty at the age of 13.
On examination, his height was 1.60 m (between 0.4th and 2nd centile), weight was 56.4 kg (between 9th and 25th centile), genital development was Tanner stage 2 and testicular volume was 8 mL bilaterally. Pubic hair was Tanner stage 2, with no evidence of androgenic axillary hair. Bone age at the left wrist was 13.5 years.
Investigations:
serum testosterone2.9 nmol/L (9.0-35.0)
Which feature in his clinical presentation most strongly suggests a diagnosis other than constitutional delay?

A) 2.5-year delay in bone age
B) failure to progress through puberty
C) absence of axillary hair in the presence of pubic hair
D) being below the 2nd centile for height
E) discordance between the height centile and the weight centile

4. An 18-year-old woman was found to have a blood pressure of 164/102 mmHg at a preemployment medical examination. She gave no family history of hypertension. On enquiry, she said that she had not yet started to menstruate.
On initial clinical examination, she appeared well. She was 1.72 m tall (>90th centile) and had a body mass index of 22 kg/m2 (18-25). There was no evidence of axillary hair, and pubic hair was scanty (Tanner stage 1). Breast development was immature (Tanner stage 1).
Investigations:
serum sodium142 mmol/L (137-144)
serum potassium2.7 mmol/L (3.5-4.9)
serum urea4.6 mmol/L (2.5-7.0)
serum creatinine102 umol/L (60-110)
estimated glomerular filtration rate (MDRD)>60 mL/min/1.73 m2 (>60)
plasma renin activity (after 30 min supine)1.0 pmol/mL/h (1.1-2.7)
plasma aldosterone (after 30 min supine)125 pmol/L (135-400)
serum cortisol (09.00 h)190 nmol/L (200-700)
What is the most likely underlying diagnosis?

A) adrenal 17-hydroxylase deficiency
B) deoxycorticosterone-secreting adrenal tumour
C) 11-hydroxysteroid dehydrogenase type 2 deficiency
D) adrenal 21-hydroxylase deficiency
E) adrenal 11-hydroxylase deficiency

5. 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) inadequate mealtime insulin bolus
B) dawn phenomenon
C) blocked infusion set
D) overcorrection of hypoglycaemia
E) inadequate basal insulin rate

Solutions: