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

1. A 42-year-old woman, with type 1 diabetes mellitus of 22 years' duration, attended for annual review. She was using biphasic insulin twice daily and taking aspirin 75 mg, simvastatin 40 mg and ramipril 10 mg daily.
On examination, her blood pressure was 164/87 mmHg.
Investigations:
serum potassium5.9 mmol/L (3.5-4.9)
serum creatinine197 umol/L (60-110)
estimated glomerular filtration rate (MDRD)26 mL/min/1.73 m2 (>60)
haemoglobin A1c72 mmol/mol (20-42)
urinary albumin:creatinine ratio27.0 mg/mmol (<3.5)
urine culturenegative
What is the most important next step in management?

A) change to intensive insulin regimen
B) refer to a nephrologist
C) add aliskiren
D) check bicarbonate
E) add furosemide

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) entry inhibitors (e.g. enfuvirtide)
D) protease inhibitors (e.g. ritonavir)
E) non-nucleoside reverse transcriptase inhibitors (e.g. nevirapine)

3. A 23-year-old barmaid presented with headache, sweating and collapse. She had a past medical history of tension headache and unexplained abdominal pain. Her regular medication included amitriptyline 25 mg at night and paracetamol 1 g as required. She was a smoker and regularly drank alcohol.
On examination, her pulse was 120 beats per minute and her blood pressure was 210/128 mmHg.
Investigations:
24-h urinary metanephrine5.4 umol (<2)
24-h urinary normetanephrine15.2 umol (<3) What substance is most likely to cause assay interference in the measurement of urinary metanephrines?

A) paracetamol
B) amitriptyline
C) nicotine
D) alcohol
E) caffeine

4. A 33-year-old woman was seen for diabetes review 2 months after her first pregnancy. Diabetes mellitus had been diagnosed at 18 weeks' gestation. She had experienced no symptoms; routine urinalysis had shown glucose 4+, with no ketones, and her fasting blood glucose concentration was 6.2 mmol/L (3.0-6.0), rising to 13.5 mmol/L (<7.8) in a 75-g oral glucose tolerance test. She had been treated with insulin during the pregnancy, and stopped after delivery. Her mother and maternal aunt had been treated for type 2 diabetes mellitus, and a maternal uncle for type 1 diabetes. Her body mass index was 23.7 kg/m2 (18-25).
Without insulin she remained well, with no osmotic symptoms, no weight loss and no ketosis.
Investigations:
fasting plasma glucose8.4 mmol/L (3.0-6.0)
haemoglobin A1c68 mmol/mol (20-42)
oral glucose tolerance test (75 g):
fasting plasma glucose7.9 mmol/L (3.0-6.0)
2-h plasma glucose13.8 mmol/L (<7.8)
serum insulin72 pmol/L (<186)
serum C-peptide945 pmol/L (180-360)
A trial of therapy with gliclazide 40 mg once daily led to a significant improvement in her blood glucose.
What is the most likely cause of her diabetes?

A) maturity-onset diabetes of the young caused by HNF-1? mutation
B) type 2 diabetes mellitus
C) type 1 diabetes mellitus
D) latent autoimmune diabetes in adulthood
E) maturity-onset diabetes of the young caused by glucokinase mutation

5. A 77-year-old woman presented with a 10-week history of facial hirsutism, scalp hair loss and deepening of the voice.
On examination, her body mass index was 32 kg/m2 (18-25). Her blood pressure was 164/94 mmHg. She had coarse terminal hairs on her upper lip and beard areas. Abdominal examination was normal, but she refused examination of her external genitalia.
Investigations:
serum sodium144 mmol/L (137-144) serum potassium3.6 mmol/L (3.5-4.9) serum urea7.7 mmol/L (2.5-7.0) serum creatinine122 umol/L (60-110) fasting plasma glucose6.4 mmol/L (3.0-6.0) serum testosterone17.2 nmol/L (0.5-3.0) serum luteinising hormone2.2 U/L (>30.0)
What is the most appropriate initial investigation?

A) serum dehydroepiandrosterone sulphate
B) overnight dexamethasone suppression test (after 1 mg dexamethasone)
C) plasma adrenocorticotropic hormone and serum cortisol
D) CT scan of abdomen and pelvis
E) serum oestradiol

Solutions: