‫ﻣﺮﻛﺰ ﻣﯿﺴﺎن اﻟﺘﺪرﯾﺒﻲ ﻟﻠﻄﺐ اﻟﺒﺎطﻨﻲ‬

‫اﻻﻣﺘﺤﺎن اﻟﺸﮭﺮي ﻟﻠﻤﻘﯿﻤﯿﻦ اﻻﻗﺪﻣﯿﻦ وطﻠﺒﺔ اﻟﺒﻮرد‬

Endocrine exam 31/3/2024

1- A 78-year-old man with type 2 diabetes mellitus is reviewed in the diabetes clinic.
He is currently taking metformin 1g bd. He also has a history of hypertension and
hypothyroidism. His HbA1c one year ago was 44 mmol/mol (6.2%). The most recent
test is reported as 46 mmol/mol (6.4%). What is the most appropriate next step in
management?
A- Increase dose of metformin
B- Add glimepiride
C- Add sitagliptin
D- Add pioglitazone
E- Make no changes

2- You review a 68-year-old patient in the diabetic clinic. He was diagnosed 28 years
ago with type 2 diabetes and over this time has been through a number of antiglycemic
agents including biguanides, sulfonylureas, thiazolidinediones and insulin. He is
generally well but reports painless macroscopic haematuria and would like to be
referred to a urologist as he has read about bladder cancer associated with one of his
medications. Which of the following antiglycemic agents can cause bladder cancer?
A- Gliclazide
B- Tolbutamide
C- Pioglitazone
D- Insulin detemir
E- Sitagliptin

3- A 24-year-old nurse presents after collapsing on a night shift. His blood glucose is
measured at being 1.4 mmol/l. His blood pressure at the time was noted to be 115/82
mmHg. He has no palpitations and had not bitten his tongue or become incontinent
during the episodes. He was shaken afterwards, although did not have memory loss
and stated he had not tripped over anything. He also said he has had five of these
episodes over the last two weeks. Blood tests are sent off and unremarkable except for
a low-normal C-peptide level and markedly raised insulin level. Which of the
following is the most likely diagnosis of his multiple episodes of collapse?
A- Sulphonylurea misuse
B- Insulin misuse
C- Alcohol misuse
D- Retroperitoneal sarcoma
E- Insulinoma

4-A 35-year-old woman is known to have a family history of multiple endocrine

neoplasia type 2a. She has tested positive for the RET oncogene and is concerned as
her mother had suffered from thyroid cancer. However, she is reluctant to undergo a
prophylactic thyroidectomy and asked if there is another option available. Which of the
following management options would be appropriate for her case?

A- Annual monitoring of thyroid peroxidase (TPO)

B- Annual monitoring of thyroglobulin
C- Annual 5 hydroxyindoleacetic acid levels (5-HIAA)
D- Annual monitoring of calcitonin
E- Annual monitoring of chromogranin A
5- A 23-year-old woman attends a fertility clinic with her partner. She complains of
oligomenorrhoea and galactorrhoea and has failed to get pregnant after 18 months of
regular unprotected intercourse. Blood tests reveal a serum prolactin level of 6000
mIU/l (normal <500 mIU/l). A pituitary MRI is arranged which shows a
microprolactinoma. Which of the following is the best initial treatment?
A- Octreotide
B- Bromocriptine
C- Trans-sphenoidal hypophysectomy
D- Pituitary radiotherapy
E- Transfrontal hypophysectomy

6- A 27-year-old woman who is 11 weeks pregnant comes for review. This is her
second pregnancy. During her first pregnancy she was diagnosed with gestational
diabetes which resolved following the birth of her son. What is the most appropriate
management at this stage?
A- Perform an oral glucose tolerance test
B- Advise on a diabetic diet and start metformin at 20 weeks
C- Arrange a fasting glucose
D- Arrange a HbA1c test
E- Advise on a diabetic diet and start insulin at 20 weeks

7- A 28-year-old woman is referred by her GP with refractory hypertension. Despite

combination therapy with ramipril, amlodipine, bendroflumethiazide and atenolol, her
blood pressure in clinic today is 181/105 mmHg. Some of her bloods are shown below.
On direct questioning she also admits passing urine more than 10 times per day. What
is the most likely diagnosis? Na+145 mmol/lK+3.0 mmol/lUrea6.0 mmol/lCreatinine71
µmol/l What is the most likely diagnosis?
A- Phaeochromocytoma
B- Coarctation of the aorta
C- Renal artery stenosis
D- 21-hydroxylase deficiency
E- Conn's syndrome

8-A 45-year-old woman comes to the clinic some 6 months after thyroid resection for
differentiated thyroid cancer. She is well, has recovered from her surgery and has a
neatly healed scar across her anterior neck. Blood pressure is normal at 110/80 mmHg,
and her pulse is 60 and regular. Her body mass index is unchanged at 25 kg/m². Only
medication is thyroid hormone replacement. Which of the following is the most
appropriate way to monitor for a recurrence?
A- MRI neck
B- Technetium scanning
C- Thyroglobulin
D- Thyroid ultrasound scan
E- T3 levels

9- 50-year-old woman is 5 ft 7 in tall and weighs 185 lb. There is a family history of
diabetes mellitus. Fasting blood glucose (FBG) is 160 mg/dL and 155 mg/dL on two
occasions. HgA1c is 7.9%. You educate the patient on medical nutrition therapy. She
returns for reevaluation in 8 weeks. She states she has followed diet and exercise
recommendations, but her FBG remains between 140 and 150 and HgA1C is 7.7%. She
is asymptomatic, and physical examination shows no abnormalities. Which of the
following is the treatment of choice?
A. A thiazolidinedione such as pioglitazone
B. A dipeptidyl peptidase-4 (DPP-4) inhibitor such as sitagliptin.
C. Insulin glargine at bedtime
D. Metformin
E. A glucagon-like-peptide-1 receptor agonist such as liraglutide

10- On routine physical examination, a 28-year-old woman is found to have a thyroid

nodule. She denies pain, hoarseness, hemoptysis, or local symptoms. Thyroid
examination shows a 1.5-cm nodule in the right lobe of the thyroid; it moves normally
with deglutition (ie, it is not fixed). No cervical lymphadenopathy is found. Serum
TSH is normal. Which of the following is the best next step in evaluation?
A. Thyroid ultrasonography
B. Thyroid scan
C. Surgical resection
D. Suppression of the nodule with exogenous thyroxine
E. No further evaluation

11- family brings their 82-year-old grandmother to the emergency room stating that
they cannot care for her anymore. They tell you, “She has just been getting sicker and
sicker. ” Now she stays in bed and won ’ t eat because of abdominal pain. She is too
weak to go to the bathroom on her own. Her symptoms have been worsening over the
past year, but she has refused to see a doctor. The patient denies symptoms of
depression. Blood pressure is 90/54 with the patient supine; it drops to 76/40 when she
stands. Heart and lungs are normal. Skin examination reveals a bronze coloring to the
elbows and palmar creases. What laboratory abnormality would you expect to find in
this patient?
A. Low serum Ca+
B. Low serum K+
C. Low serum Na+
D. Normal serum K+
E. Microcytic anemia

12. A 60-year-old woman comes to the emergency room in a coma. The patient ’ s
temperature is 32.2°C (90°F). She is bradycardic. Her thyroid gland is enlarged. There
is diffuse hyporeflexia. BP is 100/60. Which of the following is the best next step in
management?
A. Await results of T4 and TSH.
B. Obtain T4 and TSH; begin intravenous thyroid hormone and glucocorticoid.
C. Begin rapid rewarming.
D. Obtain CT scan of the head.
E. Begin intravenous fluid resuscitatin.

13- A 25-year-old woman is admitted for hypertensive crisis. The patient’s urine drug
screen is negative. In the hospital, blood pressure is labile and responds poorly to
antihypertensive therapy. The patient complains of palpitations and apprehension. Her
medical history shows that she developed hypertension during an operation for
appendicitis at age 23. Hct: 49% (normal range 37%-48%) WBC: 11,000/mm3 (4.3-10.8)
Plasma glucose: 160 mg/dL (75-115) Plasma calcium: 11 mg/dL (9-10.5) Which of the
following is the most likely diagnosis?
A. Panic attack
B. Renal artery stenosis
C. Essential hypertension
D. Type 1 diabetes mellitus
E. Pheochromocytoma

14. A 23-year-old man complains of persistent headache. He has noticed gradual

increase in his ring size and his shoe size over the years. On physical examination, he
has a peculiar deep, hollowsounding voice and a prognathic jaw. Bedside visual field
testing suggests bitemporal hemianopsia. What initial studies are indicated?
A. Serum insulin-like growth factor 1(IGF-1) and prolactin levels
B. Morning growth hormone levels
C. Overnight dexamethasone-suppressed cortisol level
D. Lateral skull film to assess sella turcica size
E. GHRH-stimulated growth hormone level

15- A 24-year-old man presents with gynecomastia and infertility. On examination, he

has small, firm testes and eunuchoid features. He has scant axillary and pubic hair.
Which of the following is correct?
A. The patient has Turner syndrome.
B. The patient will have a normal testosterone level.
C. His most likely karyotype is 47 XXY.
D. The patient will have normal sperm count.
E. The patient is likely to have low levels of gonadotropins.

16- A 30-year-old man is evaluated for a thyroid nodule. The patient reports that his
father died from thyroid cancer and that a brother had a history of recurrent renal
stones. Blood calcitonin concentration is 2000 pg/mL (normal is < 100); serum calcium
and phosphate levels are normal. The patient is referred to a thyroid surgeon. Which of
the following studies should also be obtained?
A. Obtain a liver scan.
B. Measure parathormone level.
C. Measure urinary metanephrines.
D. Administer suppressive doses of thyroxine and measure levels of
thyroid-stimulating hormone.
E. Treat the patient with radioactive iodine.

17- A 58-year-old patient who has a history of hypertension is operated on by the

neurosurgeons for an intracranial haemorrhage. Over the next few days his serum
sodium level progressively declines and by the third day has fallen to 118 mmol/l
despite fluid restriction to 1L per day. Urine osmolarity is 700 mOsmo/l and urinary
sodium is raised at 80 mmol/l. What is the most likely diagnosis?
A- Addisonian crisis
B- Secretion of inappropriate antidiuretic hormone
C- Cranial diabetes insipidus
D- Hypovolaemia
E- Fluid overload

18- A 17-year-old woman is referred to the endocrinology outpatient clinic with

primary amenorrhoea. She has no past medical history and does not take any
medications. On examination, there is no axillary or pubic hair. There are swellings
palpable in the groins bilaterally. There is normal breast development.
Testosterone1100 ng/dlMale: (300-1200)
Female : (20-75) . What is the likely diagnosis?
A- 17-alpha-hydroxylase deficiency
B- Androgen insensitivity syndrome
C- Klinefelter syndrome
D- Pituitary tumour
E- Turner syndrome

19- A 29-year-old woman comes to the clinic with feelings of anxiety, palpitations and
a resting tremor present over the past 2 weeks. She also has symptoms of a flu-like
illness and pain over her anterior neck. On examination,you reveal tenderness over the
thyroid. Her blood pressure is 115/88 mmHg, she has a fine tremor at rest, sweaty
palms and a tachycardia of 88 beats per minute. TSH is <0.05 U/ml. Which of the
following is the most appropriate intervention?
A- Thyroxine
B- Carbimazole
C- Propylthiouracil
D- Carbimazole and thyroxine
E- Propranolol

20- A 62-year-old woman with a history of type 2 diabetes comes to the clinic for
review. She has a history of mild cardiac failure managed with ramipril and bisoprolol.
Her current medication for diabetes is metformin 1g BD. On examination her blood
pressure is 122/82 mmHg, pulse is 80 beats per minute and regular. There are bilateral
basal crackles on auscultation of the chest, and pitting oedema of both ankles. Her
body mass index is elevated at 33 kg/m ² . HbA1c73 mmol/molCreatinine82 µmol/l
Which of the following is the most appropriate next step for managing glucose control?
A- Empagliflozin
B- Glipizide
C- Liraglutide
D- Pioglitazone
E- Saxagliptin

21- A 22-year-old gentleman presents to endocrinology clinic. He was referred by his

GP as he was complaining of low energy and a morning testosterone was low. He
immigrated from Albania one year ago and has been noticed to be always tired and
lacking energy. He has also found to have low sexual desire after starting a new
relationship in the UK. On examination he is tall and slim, with slight gynaecomastia.
What is the most appropriate investigation after confirming the low morning
testosterone?
A- Prolactin
B- LH and FSH
C- MRI pituitary
D- Morning cortisol
E- Synacthen test

22- A 28-year-old woman presents with flu-like symptoms, palpitations and pain over
the anterior neck over the past 2-3 weeks. She has also suffered rapid weight loss and
feels increasingly anxious that there may be something seriously wrong with her. Her
thyroid-stimulating hormone has been measured at <0.05 IU by her GP. On
examination her blood pressure is 128/82 mmHg, her pulse is 95 beats per minute and
regular, and she has a fine tremor. There is mild tenderness over the anterior neck.
Body mass index is 22 kg/m². Which of the following would you also expect to find?
A- Erythema nodosum
B- Exophthalmos
C- Multiple small thyroid nodules on ultrasound scan
D- Positive anti-thyroid antibodies
E- Reduced uptake on thyroid scintigraphy

23- A 54-year-old man with a history of type 2 diabetes is recovering on the surgical
ward having suffered an episode of acute pancreatitis some 4 days earlier. Medication
for glucose control includes metformin, dapagliflozin and liraglutide. On examination
his blood pressure is 135/80 mmHg, pulse is 72 and regular. His body mass index is 35
kg/m². A recent HbA1c is 63 mmol/mol, renal function is reported as normal. Which of
the following is the correct course of action with respect to his long term blood glucose
lowering medication?
A- Stop metformin
B- Stop dapagliflozin
C-Stop liraglutide
D- Continue usual medication
E- Stop metformin and liraglutide

24- A 45-year-old man presents to the endocrine clinic for review. He has had 3 stones
in weight gain over the past 6 months and his GP is concerned about a possible
diagnosis of Cushing's syndrome and has checked an initial 24hr urinary free cortisol
which is elevated. He is hypertensive with a blood pressure of 155/90 mmHg, his pulse
is 75 beats per minute and regular. His body mass index is 35 kg/m ² and there are
obvious abdominal striae. Which of the following would be most suggestive of an
adrenal adenoma producing cortisol?
A- Normal 9am serum cortisol
B- Raised urinary free cortisol on repeat testing
C- Serum cortisol of 220 mmol/l at 9am after an overnight dexamethasone suppression
test
D- Serum potassium of 2.4 mmol/l
E- Undetectable levels of ACTH

25- A 28-year-old woman is referred to the hospital with dysphagia. She complains of
fatigue and that she often struggles to swallow certain foods such as bread. Drinking
has not been a problem.
In addition, her eyes often feel gritty and uncomfortable. She has mild myalgia which
interferes with her job at the local bakery. What other finding would be consistent with
the most likely diagnosis?
A- C-ANCA positive
B- P-ANCA positive
C- Type 1 renal tubular acidosis
D- Type 2 renal tubular acidosis
E- Type 4 renal tubular acidosis