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MRCPUK SEND Exam Syllabus Topics:

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

1. An 18-year-old man presented to the thyroid clinic complaining of a lump in his neck that had been present for 9 weeks. It was not painful. At the age of 12, he had developed acute lymphoblastic leukaemia and had undergone a bone marrow transplant preceded by total body irradiation and cyclophosphamide.
On examination, he was euthyroid. There was a 1.5-cm firm mass on the left side of the neck, which moved when he swallowed.
Investigations:
serum thyroid-stimulating hormone1.9 mU/L (0.4-5.0)
serum free T416.8 pmol/L (10.0-22.0)
What is the most appropriate initial course of action?

A) surgical referral for hemithyroidectomy
B) ultrasound-guided fine-needle aspiration of the nodule
C) CT scan of neck and thorax
D) FDG-PET-CT scan
E) technetium-99m scintigraphy scan of thyroid

2. A 26-year-old man presented urgently, complaining of muscle pains. He had been found to have heterozygous familial hypercholesterolaemia 2 years previously owing to a mutation in the PCSK9 gene. He had a strong family history of premature vascular disease. He was taking atorvastatin 80 mg daily.
Investigations:
serum creatine kinase2782 U/L (24-195)
serum cholesterol5.7 mmol/L (<5.2)
After stopping atorvastatin, his serum creatine kinase fell to within the normal range.
What is the most appropriate next step in management?

A) restart atorvastatin 10 mg
B) start ezetimibe 10 mg
C) start fenofibrate 100 mg
D) start fluvastatin 40 mg
E) restart atorvastatin 40 mg

3. A 44-year-old man was referred for investigation of cortisol excess. He had poorly controlled hypertension, and a long history of type 2 diabetes mellitus with retinopathy and peripheral neuropathy. His medication comprised aspirin, ramipril, atenolol, carbamazepine, metformin and simvastatin.
Initial investigations:
serum cortisol (09.00 h)350 nmol/L (200-700)
serum cortisol (22.00 h)48 nmol/L (50-250)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol93 nmol/L (<50)
24-h urinary free cortisol (day 1)225 nmol (55-250)
24-h urinary free cortisol (day 2)200 nmol (55-250)
24-h urinary free cortisol (day 3)185 nmol (55-250)
What is the most appropriate next step in management?

A) dexamethasone-suppressed corticotrophin-releasing hormone test
B) MR scan of pituitary
C) high-dose 48-h dexamethasone suppression test
D) CT scan of adrenal glands
E) reassure and discharge

4. A 25-year-old woman who was 4 months pregnant presented with weight loss of 3 kg over the previous 4 weeks, associated with intermittent palpitations, tremor and feeling of warmth. She was not taking any medication.
On examination, her pulse was 100 beats per minute and regular, and her blood pressure was 130/60 mmHg. A symmetrical non-tender goitre was palpable, with an audible bruit. There was no exophthalmos.
Investigations:
serum thyroid-stimulating hormone<0.1 mU/L (0.4-5.0)
serum free T445.2 pmol/L (10.0-22.0)
serum free T322.8 pmol/L (3.0-7.0)
anti-thyroid stimulating hormone receptor
antibodies40 U/L (<7)
What is the most appropriate treatment?

A) carbimazole
B) propranolol
C) subtotal thyroidectomy
D) radioactive iodine
E) propylthiouracil

5. A 64-year-old man was reviewed in the diabetes clinic. He had a history of type 2 diabetes mellitus treated for 12 years. He had sustained a previous episode of acute kidney injury believed to be secondary to renal artery stenosis and exposure to an ACE inhibitor. He was being treated with metformin 500 mg three times daily and gliclazide 80 mg twice daily.
Investigations:
serum sodium143 mmol/L (137-144)
serum potassium4.4 mmol/L (3.5-4.9)
serum creatinine123 umol/L (60-110)
estimated glomerular filtration rate (MDRD)51 mL/min/1.73 m2 (>60)
haemoglobin A1c75 mmol/mol (20-42)
He required a third drug that would not require dose adjustment if renal function were to decline in the future.
What additional medication is most appropriate?

A) vildagliptin
B) sitagliptin
C) linagliptin
D) saxagliptin
E) alogliptin

Solutions: