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.
QUESTIONS (31–34) REFER TO THE FOLLOWING INFORMATION
Match the clinical presentation, symptoms, and signs with metabolic and nutritional complications after bariatric surgery.
1 Calcium deficiency.
2 Copper deficiency.
3 Iron deficiency.
4 Vitamin A deficiency.
5 Vitamin B1 deficiency.
6 Vitamin B12 deficiency.
7 Vitamin D deficiency.
8 Zinc deficiency.
1 31. A 50‐year‐old man underwent a gastric banding because of OSA, type 2 diabetes. Post‐surgery, he developed chronic intermittent nausea and vomiting. He is now admitted with high output heart failure.
2 32. A 48‐year‐old man underwent a gastric sleeve operation for his morbid obesity 12 months ago. On his annual outpatient review, he complains of tingling in fingers and toes. He states that his memory is very poor. He has a tendency to stumble. He is diagnosed to have depression by his GP recently despite the significant weight loss. His blood test arranged by his GP shows macrocytic anaemia and mild abnormal LFTs.
3 33. A 49‐year‐old woman reported flashes in the eyes with poor night vision and reduced visual acuity for 8 weeks. She had a Roux‐en‐Y gastric bypass surgery 3 years ago. Ophthalmology evaluations revealed bilateral visual acuity of 6/36. Humphrey visual fields showed peripheral constriction in both eyes without a central scotoma. Slit‐lamp examination revealed conjunctival xerosis in both eyes. Bitot's spots and relative afferent papillary defects were absent. Fundoscopy examination revealed optic atrophy but normal appearing macula, vessels, and peripheral retina in both eyes.
4 34. A 48‐year‐old woman underwent a biliopancreatic diversion several years ago. She suffers skin or respiratory tract infections frequently. Her skin wound heals very slowly. She complains of blunting of taste sense, hair loss leading to alopecia. There is clinical evidence of glossitis.
QUESTIONS (35–5–36) REFER TO THE FOLLOWING INFORMATION
Match the clinical presentation with the appropriate endocrine investigations.
1 24‐hour urinary catecholamines and metanephrines.
2 24‐hour urinary cortisol.
3 Blood renin/aldosterone ratio.
4 Plasma vasopressin level.
5 Saline
