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

1. A 63-year-old woman was incidentally found to have a 3-cm right adrenal mass on a CT scan of abdomen during investigation for abdominal pain. Her medical history included angina, hypertension and hypercholesterolaemia. She was taking oestrogen-containing hormone replacement therapy, atenolol, bendroflumethiazide, simvastatin and aspirin.
On examination, her pulse was 60 beats per minute and regular, and her blood pressure was 150/90 mmHg. She was obese with a body mass index of 34 kg/m2 (18-25). Fundoscopy revealed grade II hypertensive retinopathy.
Investigations:
serum sodium137 mmol/L (137-144)
serum potassium3.0 mmol/L (3.5-4.9)
serum creatinine100 umol/L (60-110)
plasma renin activity (after 30 min supine)0.4 pmol/mL/h (1.1-2.7)
plasma aldosterone (after 30 min supine)200 pmol/L (135-400)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol75 nmol/L (<50)
24-h urinary free cortisol140 nmol (55-250)
24-h urinary metanephrine<1 umol (<2)
24-h urinary normetanephrine1 umol (<3)
What is the most likely cause of the hypertension?

A) Conn's syndrome
B) essential hypertension
C) renovascular disease
D) Cushing's syndrome
E) phaeochromocytoma

2. A 71-year-old man was brought to the emergency department in a collapsed state. He was
unable to give a history. Records showed that he had ischaemic heart disease and had undergone coronary bypass grafting 2 years previously. He was taking bendroflumethiazide 2.5 mg daily and simvastatin 40 mg at bedtime.
On examination he was unwell. His pulse was 128 beats per minute and his blood pressure was 108/60 mmHg. Oxygen saturation was 96% (94-98) breathing air.
An ECG showed Q waves in leads II, III, and aVF.
Investigations:
serum sodium164 mmol/L (137-144)
serum potassium5.4 mmol/L (3.5-4.9)
serum bicarbonate19 mmol/L (20-28)
serum urea15.2 mmol/L (2.5-7.0)
serum creatinine145 umol/L (60-110)
random plasma glucose81.2 mmol/L
What is the most appropriate fluid replacement?

A) sodium chloride 0.45%
B) colloid
C) sodium chloride 0.9% and glucose 5%
D) sodium chloride 0.9%
E) compound sodium lactate intravenous infusion

3. 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 0.18% and glucose 5%
C) sodium chloride 0.18% and glucose 4%
D) sodium chloride 0.45%
E) sodium chloride 0.9%

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

5. A 46-year-old South Asian man presented with a 2-month history of dry mouth and polyuria. He had hypertension treated with bendroflumethiazide. There was no family history of diabetes mellitus, but his father had died suddenly during lower limb angioplasty at the age of 51.
On examination, the patient's pulse was 76 beats per minute and regular, and his blood pressure was 164/86 mmHg. The rest of the physical examination was normal. Urinalysis was normal.
Investigations:
serum sodium143 mmol/L (137-144)
serum potassium3.0 mmol/L (3.5-4.9)
serum creatinine123 umol/L (60-110)
fasting plasma glucose6.9 mmol/L (3.0-6.0)
What is the most appropriate next step in management?

A) haemoglobin A1c measurement
B) oral glucose tolerance test
C) start oral hypoglycaemic treatment
D) change bendroflumethiazide to ramipril
E) repeat fasting plasma glucose

Solutions: