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

1. A 56-year-old man was referred urgently by an ophthalmologist after presenting with a 6month history of deteriorating vision. The patient had a 40 pack-year smoking history. Before his vision problem, he had never visited his general practitioner.
Investigations:
serum cortisol (09.00 h)389 nmol/L (200-700) serum testosterone8.6 nmol/L (9.0-35.0) plasma follicle-stimulating hormone2.1 U/L (1.0-7.0) plasma luteinising hormone2.4 U/L (1.0-10.0) serum prolactin896 mU/L (<360) serum thyroid-stimulating hormone1.4 mU/L (0.4-5.0)
MR scan of pituitarysee image

What is the most likely diagnosis?

A) non-functioning adenoma
B) prolactinoma
C) craniopharyngioma
D) meningioma
E) Rathke's cyst

2. A 62-year-old man was referred from the infectious diseases clinic. He had HIV infection and was taking treatment that included thymidine analogue nucleoside reverse transcriptase inhibitors. He had developed considerable loss of limb and gluteal subcutaneous fat. He had complained recently of polyuria and polydipsia and was found to have a fasting plasma glucose of 8.3 mmol/L (3.0-6.0).
What is the most appropriate treatment for his diabetes mellitus?

A) insulin
B) exenatide
C) pioglitazone
D) gliclazide
E) metformin

3. A 16-year-old Caucasian girl presented with a 4-year history of facial hair growth, acne and secondary amenorrhoea.
On examination, her body mass index was 20 kg/m2 (18-25). Her gums and palmar creases were pigmented. Facial hair was evident on her upper lip and chin, and terminal hair was evident on her chest and abdomen. Her Ferriman-Gallwey score was 25. She had acne affecting her face and back.
Investigations:
serum dehydroepiandrosterone sulphate15 umol/L (3-12)
serum androstenedione12.2 nmol/L (0.6-8.8)
serum 17-hydroxyprogesterone120 nmol/L (1-10)
serum testosterone6.0 nmol/L (0.5-3.0)
serum sex hormone binding globulin18 nmol/L (40-137)
What treatment is likely to be of most benefit?

A) hydrocortisone
B) flutamide
C) fludrocortisone
D) cyproterone acetate
E) metformin

4. A 58-year-old man was referred to the endocrine clinic after a CT scan of abdomen had shown a 4.5-cm left adrenal mass, with a Hounsfield unit measurement of 11 (consistent with high lipid content). He had a 10-year history of type 2 diabetes mellitus and was taking metformin. He was also taking atenolol for hypertension.
On examination at the clinic, his blood pressure was 162/94 mmHg. He was centrally obese with a body mass index of 27 kg/m2 (18-25).
Investigations:
serum potassium3.9 mmol/L (3.5-4.9)
plasma renin activity (after 30 min upright)1.0 pmol/mL/h (3.0-4.3)
plasma aldosterone (after 4 h upright)680 pmol/L (330-830)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol164 nmol/L (<50)
24-h urinary free cortisol132 nmol (55-250)
24-h urinary catecholamines
(adrenaline and noradrenaline)normal
As the lesion was >4 cm in diameter, laparoscopic adrenalectomy was recommended.
What is the most appropriate advice to give to the surgical team about perioperative
management?

A) no special precautions are required
B) give preoperative ?-adrenergic receptor blockade in case the lesion is an occult phaeochromocytoma
C) measure cortisol and aldosterone 2 weeks postoperatively
D) give corticosteroid cover during and after surgery and reassess postoperatively
E) short tetracosactide (Synacthen@) test 48 h postoperatively

5. A 62-year-old woman was referred with generalised weakness. She had no previous history of note and was not taking any medication. She reported drinking 60 units of alcohol per week.
On examination, she was found to have central adiposity, pale abdominal striae and
wasting of the limb muscles. Her blood pressure was raised at 160/100 mmHg.
Investigations:
serum sodium138 mmol/L (137-144)
serum potassium3.8 mmol/L (3.5-4.9)
serum cortisol (09.00 h)750 nmol/L (200-700)
low-dose dexamethasone suppression test (2 mg/day for 48 h):
serum cortisol120 nmol/L (<50)
high-dose dexamethasone suppression test (8 mg/day for 48 h):
serum cortisol45 nmol/L (should suppress to
<50% of day 0 value)
24-h urinary free cortisol 360 nmol (55-250)
plasma adrenocorticotropic hormone (09.00 h)22.0 pmol/L (3.3-15.4)
MR scan of pituitary glandnormal
CT scan of adrenal glands1-cm mass in the left adrenal gland
What is the most likely cause for her presentation?

A) pseudo-Cushing's syndrome
B) adrenal carcinoma
C) Cushing's disease
D) ectopic adrenocorticotropic hormone syndrome
E) adrenal adenoma

Solutions: