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Answers can be found in the Endocrinology Answers section at the end of this chapter.

1 1. A 48‐year‐old woman is referred by her GP with a 3‐month history of headaches and night sweats for investigation. Her medical history includes difficult to control hypertension for 5 years which requires 3 agents; OSA on CPAP treatment, glucose intolerance, and total hysterectomy 7 years ago. On examination, BP is 156/95 mmHg, her hands are large, and she is no longer able to wear her ring. There is no hirsutism buts there is coarseness of her facial features. Her laboratory test results and MRI of head are shown below.TestsResultsNormal valuesHbA1c6.5%<6.0%Cortisol (9 am)320 nmol/L133–540Free T415 pmol/L10–20Prolactin278 mIU/L90–630Estradiol48 pg/ml15–350Growth hormone (GH)362 pmol/L<226Insulin like growth factor 1 (IGF‐1)748 ng/ml<320What is the most appropriate next step for this patient? Inferior petrosal sinus sampling for growth hormone.Measurement of growth hormone after insulin induced hypoglycaemia.Measurement of growth hormone releasing hormone (GHRH).Referral to neurosurgery.

2 2. A 28‐year‐old woman presents to the emergency department with symptoms of nausea, vomiting, diarrhoea, severe lethargy, weakness, and drowsiness. Her BP is 85/45 mmHg, heart rate is 98 bpm, respiratory rate is 13/min, blood glucose level is 5.6 mmol/L [3.2–5.5 fasting], and temperature is 38°C. Her serum sodium level is 130 mmol/L [135–145] and potassium level is 5.8 mmol/L [3.5–5.2]. You find a MedicAlert necklace which says, ‘Adrenal insufficiency’.Which one of the following steps of management is INCORRECT?Administer IV hydrocortisone 100 mg stat followed by IV hydrocortisone 50 mg qid.Administer IV 0.9% normal saline 1 L within the first hour.Avoid giving corticosteroid due to the potential risks of worsening sepsis.Perform a septic screen and start empirical broad‐spectrum antibiotics.

3 3. A 65‐year‐old woman was referred by her GP to the general medicine clinic with a 2.5 cm adrenal mass during investigation for abdominal discomfort. She reports no symptoms of headache, sweating, palpitations, significant weight changes, night sweats, fever, nausea, vomiting or proximal muscle weakness. She has a history of hypertension, type 2 diabetes, obesity, and osteoporosis.Which one of the following investigations is NOT indicated at this stage?24‐hr urinary fractionated metanephrine and catecholamine collection.Overnight dexamethasone (1 mg) suppression test.Plasma aldosterone and plasma renin activity measurement.Positron‐emission tomography (PET) scan.

4 4. A 65‐year‐old man is referred to the endocrine clinic with a 6‐week history of unintentional weight loss (5 kg), diarrhoea, myopathy and lethargy. He has a history of atrial fibrillation, diagnosed one year previously. He was started on amiodarone and warfarin but he reverted to sinus rhythm spontaneously at which point the amiodarone was stopped 6 months prior to presentation. On examination, there is no obvious goitre. He has an irregularly irregular pulse at 90 bpm. His skin is warm and sweaty. His TSH level is 0.2 mIU/L [0.4–4.0], Free T4 level 30 pmol/L [9.0–25.0], and Free T3 10–pmol/L [3.5–7.8].Which one of the following management strategies is correct?Commence carbimazole.Commence high‐dose oral prednisolone.Commence carbimazole and high‐dose oral prednisolone.Referral for thyroidectomy.

5 5. A 23‐year‐old woman presents to hospital because of a 3‐day history of confusion, cough, white sputum and fever. She is diagnosed with a lower respiratory tract infection and commenced on intravenous penicillin and normal saline infusion. She was diagnosed with type 1 diabetes at age 6. She is currently receiving short acting insulin three times a day before meals and insulin glargine at night. She has had several hypoglycaemic episodes recently. She has been intermittently taking thyroxine 100 mcg daily for 5 years after being diagnosed with hypothyroidism. She has not been feeling well in the past 4 months, experiencing fatigue, nausea, poor appetite, and weight loss of approximately 7 kg. On examination, she is afebrile, BP is 85/50 mmHg and HR is 110 bpm, the rest of her physical examination is unremarkable. The initial investigation results are shown below.TestsResultsNormal valuesSodium128 mmol/L135–145Potassium5.5 mmol/L3.5–5.2Bicarbonate24 mmol/L22–32Urea28 mmol/L2.7–8.0Creatinine123 μmol/L45–90Glucose16.3 mmol/L3.2–5.5Calcium2.95 mmol/L2.1–2.6Hb140 g/L115–155WBC7.1 x109/L4–11CRP7 mg/L0–8HbA1c8.6%<6%What is the most appropriate immediate next treatment?Commence insulin infusion.Give double dose of thyroxine immediately.Give intravenous norepinephrine.Intravenous hydrocortisone.

6 6. Which one of the following is a characteristic of brown adipocytes?Adiponectin secretion.Leptin secretion.Storage of energy‐yielding triglycerides.Uncoupling protein 1–containing mitochondria.

7 7. A 37‐year‐old woman is referred by her GP following a low energy fracture to her right distal radius. She is a current heavy smoker. She is diagnosed to have osteoporosis with bone mineral density Z score of –2.8 in the lumbar spine. She is obese with BMI 33 kg/m2. BP is 150/95 mmHg. She has facial rubor and proximal muscle weakness. Her 24‐hour urine free cortisol excretion is 55 μg [3.5–45]. Baseline serum 8 a.m. cortisol level is 320 μg/L [70–280] and is 310 μg/L the following morning after taking 1 mg dexamethasone. The baseline plasma level of adrenocorticotropic hormone (ACTH) is 8 pg/ml [10–90].Where is the most likely anatomical location of her clinical presentations?Adrenal cortex.Hypothalamus.Lung.Pituitary gland.

8 8. While treating a patient with stage 2 CKD due to diabetic nephropathy (DN) with significant proteinuria and hypertension, which one of the recommendations is appropriate?ACE inhibitor has better renoprotective effects in patients with DN than angiotensin II receptor blocker (ARB) and the renoprotective effect of ACE inhibitor is dose‐related.Dual Renin‐Angiotensin‐Aldosterone System (RAAS) blockade with both ACE inhibitor and ARB should be prescribed as it has better antiproteinuric effect compared to monotherapy.Intensive glycaemic control in patients with type 2 diabetes reduces incidence and progression of DN and all‐cause mortality.Intensive glycaemic control reduces progression of DN in type 1 diabetes; this benefit persists even after the patient returns to suboptimal glycaemic control.

9 9. A 32‐year‐old man presents to the emergency department with nausea, vomiting, and diffuse abdominal pain. He has had type I diabetes since age 7, which is treated with an intensive insulin regimen (insulin glargine 24 IU at bedtime and rapid‐acting insulin analogue before each meal). On examination, he is febrile and tachypnoeic. HR is 106 bpm and BP is 90/60 mmHg; he also has dry mucous membranes and poor skin turgor. He is slightly confused. The result of the strip for ketone bodies in urine is strongly positive and the concentration of β –Hydroxybutyric acid (β–OHB) in serum is elevated at 3.5 mmol/L [<0.5]. His ABG at room air demonstrates pH 7.11, PO2 95 mmHg, PCO2 28 mmHg. His other initial investigation results are shown below.TestsResultsNormal valuesSodium149 mmol/L135–145Potassium4.5 mmol/L3.5–5.2Bicarbonate11 mmol/L22–32Urea28 mmol/L2.7–8.0Creatinine143 μmol/L60–110Glucose26.3 mmol/L3.2–5.5Calcium2.85 mmol/L2.10–2.60Hb138 g/L135–175WBC17.1 x109/L4–11CRP57 mg/L0–8HbA1c9.6%–Which one of the following resuscitation treatment plans suggested by the emergency department team is the LEAST appropriate?Intravenous 0.9% sodium chloride 1000 ml/hour.Intravenous 8.4% sodium bicarbonate 100 ml over 1 hour.Intravenous potassium replacement with second bag of 0.9% sodium chloride.Intravenous short acting insulin and hold long‐acting insulin analogue.

10 10. A 58‐year‐old man is concerned regarding his inability to maintain an erection satisfactory for sexual intercourse over the past 6 months. He has had type 2 diabetes for 10 years, but his glycaemic control has been good with the most recent HbA1c at 7%. His other medical problems include hypertension, peripheral vascular disease, and hyperlipidaemia. His medication includes perindopril, gliclazide, metformin, amlodipine, and atorvastatin.Which of the following is INCORRECT regarding the management of erectile dysfunction?Measure morning total testosterone levels.Perform an exercise stress echocardiogram.Sildenafil treatment increases overall cardiovascular risk.Sildenafil treatment has a 65% chance of enabling satisfactory intercourse.

11 11. Which of the following chemotherapeutic agents carries the highest risk for inducing premature ovarian failure?Cyclophosphamide.Doxorubicin.Gemcitabine.Paclitaxel.

12 12. A 70‐year‐old man presents for follow‐up after recent initiation of citalopram for his depressed mood. He reports that his mood and sleep have improved, but his lethargy, low libido, and erectile dysfunction have not. He has a past history of type 2 diabetes. His BMI is 29 kg/m2. His HbA1c is 8.2%. His other current medications are empagliflozin and metformin. His fasting serum total testosterone level is between 6.4 and 6.7 nmol/L [8–30] on repeated measures, serum prolactin is 120 mIU/L [<325].Which of the following clinical benefits is he most likely to experience as a result of testosterone treatment?Better glycaemic control.Decreased fracture risk.Improved erectile function and libido.More energy.

13 13. A 35‐year‐old man with ESKD is on chronic haemodialysis. He has severe secondary hyperparathyroidism and has undergone a parathyroidectomy. Which one of the following biochemical abnormalities is the most likely to cause significant post‐operative complications and will require intensive monitoring post‐parathyroidectomy?Hypocalcaemia.Hypokalaemia.Hypomagnesaemia.Hypophosphataemia.

14 14. Which of the following metabolites is particularly important for macrophage and dendritic cell function?Citrate.Fumarate.Malate.Oxaloacetate.

15 15. A 29‐year‐old man has hypercalcaemia due to primary hyperparathyroidism which was treated with subtotal parathyroidectomy. During the perioperative period he complains of episodic headaches and palpitations. He is found to be hypertensive. Further investigations reveal that his 24‐hour urinary noradrenaline and adrenaline are 615 nmol/L [0–450] and 750 nmol/L [0–100] respectively. His serum calcitonin is also elevated at 135.5 ng/L [0–5.5].Which one of the following genes should be considered for mutational analyses?CDNK1B gene.MEN1 tumour suppressor gene.RET proto‐oncogene.Von Hippel‐Lindau (VHL) gene.

16 16. Which one of the following tests is LEAST useful in distinguishing between type 1 diabetes and maturity‐onset diabetes of the young (MODY)?C‐Peptide levels.Insulin autoantibodies (IAA).Islet cell cytoplasmic autoantibodies (ICA).Ketonuria.

17 17. Which of the following options best describe the pathogenesis of Paget's disease of bone?Increased osteoclast and osteoblast activity.Increased osteoclast and reduced osteoblast activity.Reduced osteoclast and increased osteoblast activity.Reduced osteoclast and osteoblast activity.

18 18. Regarding painful diabetic neuropathy, which of the following is correct?Approximately 80% of patients with diabetic neuropathy will suffer from pain.The prevalence of painful neuropathy in type 2 diabetes is more than twice that seen in type 1 diabetes.The intensity of pain is proportional to the degree of neuropathy.Tight glycaemic control in type 2 diabetes reduces the occurrence of painful neuropathy.

19 19. Which of the statements describing the pathogenesis of diabetic gastroparesis is INCORRECT?Enteric neuropathy increases transient lower oesophageal sphincter relaxation.Hyperglycaemia induces pyloric contraction, antral hypomotility and delays gastric emptying.Loss of interstitial cells of Cajal is the commonest enteric neuropathological abnormality in diabetic gastroparesis.Vagal neuropathy leads to reduced pyloric relaxation and impaired antral contraction.

20 20. A 35‐year‐old woman is diagnosed with phenotype A polycystic ovarian syndrome. Which one of following is NOT an associated consequence?Associated with 80% of cases of anovulatory infertility.Associated with increased risk of breast cancer.Associated with increased risk of endometrial cancer.Associated with increased risk of non‐alcoholic fatty liver disease.

21 21. A 63‐year‐old woman has resistant hypertension. She is currently taking four antihypertensive medications. She is referred to the general medicine outpatient clinic by her GP after the discovery of a mildly elevated plasma metanephrine level. The GP is concerned that she may have a phaeochromocytoma.What is the next most appropriate investigation?24‐hour urinary fractionated catecholamines and metanephrines.24‐hour urinary vanillylmandelic acid.Plasma catecholamines and metanephrines.MRI abdomen.

22 22. A 42‐year‐old woman with known type 1 diabetes presents to renal outpatient clinic for review of worsening renal function. Her type 1 diabetes is treated with glargine and short acting insulin Novorapid. She is waiting gynaecology appointment review for irregular vaginal bleeding, and also has chronic liver disease due to excessive alcohol consumption. You note her most recent HbA1c is 10.5% and her usual reading in the past is 8.5%. Her mean blood glucose measurement before meals in the past 3 months is 10.5mmol/L, which is consistent with an HbA1c of 8.3%.What is the most likely cause for the worsening of HbA1c in this patient?Chronic alcoholism.Chronic liver disease.Iron deficiency due to vaginal bleeding.Worsening of chronic kidney disease.

23 23. A 55‐year‐old woman presents with a 2‐month history of frontal headache. She reports having two car accidents recently which she attributed to not being able to see the right side of her car as she changed lanes. She had menopause at age of 50 and has no significant medical history and is taking no medications. The neurological examination reveals a right superior temporal visual field deficit. Her MRI head is shown below. Further investigation reveals normal TSH and T4 levels. Her IGF‐1, LH, FSH levels are also normal. Her early morning cortisol level is slightly low but the short Synacthen test demonstrates normal serum cortisol levels post‐Synacthen. The prolactin level is 54 ng/mL [<20].What is the most appropriate next step in her management plan?Consider transsphenoidal surgery.Start cabergoline.Start cortisol replacement.Watch and wait approach, repeat macroprolactin level.

24 24. A 27‐year‐old farmer suffers from brittle type 1 diabetes with impaired hypoglycaemic awareness. He is currently on a basal bolus regimen. His most recent HbA1c is 7.1%. You are considering real‐time continuous glucose monitoring (RTCGM). Which one of the clinical statements regarding the usage of RTCGM in this patient is correct?RTCGM provides continuous accurate measurement at 1–5 min increments of blood glucose concentrations.RTCGM provides no benefit in this patient because he is not using an insulin pump.RTCGM reduces time spent in the hyperglycaemic ranges but not hypoglycaemic range due to less accurate measurement at lower glucose.RTCGM will benefit this patient despite having achieved good blood glucose control.

25 25. Which of the following complications is most clearly and often associated with treatment with dapagliflozin in comparison to other diabetic treatments?Acute kidney injury.Amputation.Diabetic ketoacidosis.Urinary tract infection.

26 26. A 32‐year‐old woman presents with fatigue and self‐reported memory issues. She has no deficits on formal cognitive testing. She has no significant past medical or surgical history. Basic investigations reveal normal full blood examination, electrolytes, and liver function tests. Urine pregnancy test is negative. Thyroid function tests reveal FT4 of 12 pmol/L [10–20] and TSH of 6.7 mIU/L [0.5–4.5].Which of the following options represents the most appropriate next step?Initiate levothyroxine treatment.Measure thyroid stimulating antibodies.No further action required.Repeat TSH and T4 measurement in 1–3 months.

27 27. A 65‐year‐old woman has had a total thyroidectomy and radioactive iodine for treatment of papillary thyroid carcinoma. She had an excellent response to the initial treatment and is on an appropriate dose of thyroxine therapy. Six months later a neck ultrasound showed no residual thyroid disease.What other investigation should be performed at this time?Anti‐thyroperoxidase antibody.Anti‐thyroid stimulating hormone receptor antibody.Thyroglobulin.Whole body bone scan.

28 28. In which of the following pathways are driver mutations most frequently found in thyroid cancer?Mitogen‐activated protein kinase (MAPK).Myc.Phosphoinositide 3‐kinase/protein kinase B/mechanistic target of rapamycin (PI3k/AKT/mTOR).Tumour protein p53.

29 29. A 38‐year‐old man presents to his GP with a 3 cm mobile thyroid nodule. His thyroid function tests are normal. A fine‐needle aspirate is performed under ultrasound guidance. The cytologic findings are reported as non‐diagnostic.What is the next most appropriate investigation?Analyse fine‐needle aspirate for BRAF and RAS mutation.Measure serum calcitonin level.Repeat fine‐needle aspiration within 3 months.Repeat thyroid ultrasound within 6 months.

30 30. A 37‐year‐old transgender (TGD) person is seeking feminising hormone therapy. Which one of the following should be avoided in the gender‐affirming medical care?Anti‐androgens should be avoided.Cyproterone acetate should be avoided.Gonadotrophin‐releasing hormone analogues should be avoided.Progestins should be avoided.