MRCPUK SEND

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

1. A 73-year-old man had been attending the diabetes clinic for 6 weeks with an ulcer on his right second metatarsal head. He had been receiving regular podiatry and offloading.
What new feature in the appearance of his foot is most likely to suggest the need to start antibiotics?

A) skin redness around ulcer
B) pain around ulcer
C) tracking sinus
D) ulcer probing to bone
E) increase in ulcer size

2. A 75-year-old woman presented with a 4-week history of lethargy. Her medical history was unremarkable and she took no medication.
On examination, her blood pressure was 140/70 mmHg lying. She was euvolaemic.
Investigations:
serum sodium120 mmol/L (137-144)
serum potassium3.8 mmol/L (3.5-4.9)
serum urea3.0 mmol/L (2.5-7.0)
serum creatinine75 umol/L (60-110)
short tetracosactide (Synacthen@) test (250 micrograms):
baseline serum cortisol450 nmol/L (200-700)
serum cortisol (30 min after tetracosactide)600 nmol/L (>550)
serum thyroid-stimulating hormone2.5 mU/L (0.4-5.0)
serum free T416.9 pmol/L (10.0-22.0)
urinary sodium70 mmol/L
What is the most appropriate initial management?

A) demeclocycline
B) fluid restriction
C) tolvaptan
D) intravenous sodium chloride 0.9%
E) hydrocortisone

3. A 55-year-old woman presented with thirst, polyuria and polydipsia. Her symptoms had started 9 months previously following a road traffic accident. Her past medical history was normal and she was not taking any regular medication.
On examination, her blood pressure was 130/80 mmHg with no postural drop. Urine volume measured 5 L in 24 hours.
Investigations:
serum sodium131 mmol/L (137-144) serum potassium3.6 mmol/L (3.5-4.9) serum urea2.0 mmol/L (2.5-7.0) serum corrected calcium2.40 mmol/L (2.20-2.60) fasting plasma glucose6.4 mmol/L (3.0-6.0) serum osmolality278 mosmol/kg (278-300) urinary osmolality100 mosmol/kg (100-1000)
What is the most likely diagnosis?

A) syndrome of inappropriate antidiuretic hormone
B) primary polydipsia
C) nephrogenic diabetes insipidus
D) cranial diabetes insipidus
E) diabetes mellitus

4. A 33-year-old man was referred to the diabetes clinic with an 8-month history of weight loss and polydipsia. Two months previously his general practitioner had found a high fasting plasma glucose concentration of 17.5 mmol/L (3.0-6.0) and a haemoglobin A1c of 116 mmol/mol (20-42). The patient was taking metformin 1 g twice daily. He reported in the diabetes clinic that his home capillary blood glucose concentrations persisted to be high, ranging between 15-24 mmol/L.
On examination, his body mass index was 23 kg/m2 (18-25).
His blood tests were repeated in the diabetes clinic and he was treated with a basal bolus insulin regimen. Urinalysis was negative for ketones.
Investigations (in diabetes clinic):
haemoglobin A1c110 mmol/mol (20-42)
serum C-peptide200 pmol/L (180-360)
anti-glutamic acid decarboxylase (GAD)
antibodies69 IU/mL (<10)
anti-IA2 antibodiesnegative
What is the most likely diagnosis?

A) maturity-onset diabetes of the young
B) latent autoimmune diabetes in adults
C) mitochondrial diabetes mellitus
D) type 1 diabetes mellitus
E) haemochromatosis

5. A 64-year-old man, who was undergoing investigation for altered bowel habit, was referred to the endocrine clinic after a CT scan of abdomen had shown a 4-cm mass in his left adrenal gland. He had a history of hypertension and type 2 diabetes mellitus.
Investigations:
low-dose dexamethasone suppression test (2 mg/day for 48 h):
serum cortisol350 nmol/L (<50)
24-h urinary free cortisol400 nmol (55-250)
plasma adrenocorticotropic hormone (09.00 h)2.0 pmol/L (3.3-15.4)
He underwent laparoscopic removal of his left adrenal gland.
How should his endocrine condition be managed following surgery?

A) immediate postoperative tetracosactide (Synacthen@) test and, if abnormal, start hydrocortisone
B) introduce hydrocortisone and fludrocortisone postoperatively according to blood pressure and electrolytes
C) start hydrocortisone perioperatively and continue until tetracosactide (Synacthen@) test in 6 weeks
D) 24-h urinary cortisol 6 weeks postoperatively and start hydrocortisone if abnormally low
E) tetracosactide (Synacthen@) test 6 weeks postoperatively and start hydrocortisone if abnormal

Solutions: