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
