Endocrinology & Diabetes Practice Questions

Q: A 32-year-old woman presents with palpitations and anxiety. Examination reveals a fine tremor, warm moist skin, and a smooth, non-tender goitre. Thyroid function tests show TSH <0.05 mU/L (0.5-5.0), free T4 32 pmol/L (9-25), free T3 12.4 pmol/L (3.5-6.5). TSH receptor antibodies are positive. She is planning pregnancy in the next 6 months. What is the most appropriate initial management?

Propylthiouracil. ***Propylthiouracil*** - **Propylthiouracil (PTU)** is the initial treatment of choice for hyperthyroidism in women who are **planning pregnancy** or are in the **first trimester**, due to a lower risk of **teratogenesis** compared to Carbimazole. - It is preferred to avoid potential Carbimazole-induced **congenital malformations** such as aplasia cutis or choanal atresia, which are linked to its use in early pregnancy. *Carbimazole titration regime* - Although a standard first-line therapy for **Graves' disease** in non-pregnant individuals, this regime is generally avoided in patients **planning pregnancy** due to its known **teratogenic potential**. - Use in early pregnancy is associated with specific defects like **aplasia cutis**, often necessitating a switch to PTU if conception occurs. *Carbimazole block and replace regime* - This regime uses high-dose antithyroid drugs to block thyroid hormone production combined with **Levothyroxine** supplementation. - The inclusion of **Levothyroxine** makes this regime unsuitable for pregnancy, as it complicates accurate assessment of fetal and maternal thyroid function and may lead to poor **fetal thyroid control**. *Radioiodine therapy* - **Radioiodine therapy** is definitively contraindicated during **pregnancy** and requires patients to delay conception for at least **6 months** post-treatment. - Given the patient's plan to conceive within the next 6 months, this option is inappropriate due to the necessary waiting period and absolute contraindication. *Propranolol alone* - **Propranolol** is effective for symptomatic control of **hyperthyroidism**, alleviating symptoms like **palpitations**, anxiety, and tremor. - However, it does not treat the underlying **thyrotoxicosis** by reducing thyroid hormone synthesis and therefore cannot be used as monotherapy for Graves' disease.

Q: A 69-year-old man with type 2 diabetes presents to the emergency department with confusion. His wife reports he has had diarrhoea and vomiting for 4 days. On examination, he is drowsy but rousable, blood pressure 95/60 mmHg, heart rate 105 bpm. Capillary glucose is 42.8 mmol/L. Blood tests show sodium 152 mmol/L, urea 18.4 mmol/L, creatinine 185 µmol/L, serum osmolality 348 mOsm/kg. Venous blood gas shows pH 7.36, ketones 0.4 mmol/L. What is the diagnosis?

Hyperosmolar hyperglycaemic state. ***Hyperosmolar hyperglycaemic state*** - This diagnosis is confirmed by the combination of extreme **hyperglycaemia** (42.8 mmol/L), severe **hyperosmolality** (348 mOsm/kg), and the absence of significant **ketonemia** (0.4 mmol/L) or **acidosis** (pH 7.36). - It typically presents in elderly **type 2 diabetics** with a long history of symptoms (4 days of diarrhoea and vomiting) leading to profound **dehydration** as evidenced by hypotension and acute kidney injury. *Diabetic ketoacidosis* - Characterized by the triad of hyperglycemia, significant **ketonemia** (>3.0 mmol/L), and **metabolic acidosis** (pH <7.3), which are absent here (ketones 0.4 mmol/L, pH 7.36). - Typically presents more acutely in **type 1 diabetes** and includes symptoms like abdominal pain and Kussmaul respirations, which are not described. *Euglycaemic diabetic ketoacidosis* - Defined by the presence of **ketoacidosis** (acidosis and ketonemia) despite having **normal or only mildly elevated blood glucose** (<11 mmol/L). - This patient’s glucose levels are extremely high (42.8 mmol/L), and his **blood pH** is within the normal range, ruling out this condition. *Acute kidney injury with hyperglycaemia* - While the patient does have **acute kidney injury** (elevated urea and creatinine) and **hyperglycaemia**, these are components of the broader syndrome of HHS. - This option fails to capture the defining characteristic of severe **hyperosmolality** and the overall clinical picture of a diabetic emergency. *Mixed DKA and HHS* - This diagnosis requires meeting the diagnostic criteria for both DKA and HHS, specifically significant **ketosis** and **metabolic acidosis** occurring alongside extreme hyperosmolality. - Since the **pH is 7.36** (normal) and **ketones are 0.4 mmol/L** (below diagnostic thresholds), the criteria for the DKA component are not met.

Q: What is the recommended frequency for diabetic retinopathy screening in adults with type 1 or type 2 diabetes who have no evidence of retinopathy?

Annually. ***Annually***- For adults with **Type 1** or **Type 2 diabetes** who show no signs of retinopathy, the standard clinical recommendation is an **annual retinal screening** to detect early microvascular changes.- **Annual screening** is crucial because diabetic retinopathy is a major cause of **preventable blindness**, and regular checks allow for timely intervention if damage begins.*Every 6 months*- **Six-month intervals** are typically reserved for patients who already have **pre-existing retinopathy** or for monitoring during **pregnancy**.- Using this frequency for patients with no evidence of disease would lead to unnecessary clinical burden without significant diagnostic gain.*Every 2 years*- While some health systems consider **biennial screening** for patients with consistently stable **glycemic control**, the current standard of care for most guidelines remains annual.- Extending the interval to **2 years** may miss rapid progression if a patient's metabolic state happens to deteriorate suddenly.*Every 3 years*- A **3-year interval** is too long and increases the risk of **proliferative retinopathy** or **macular edema** developing unnoticed between exams.- Most international specialist bodies, such as the **ADA** and **NHS**, do not support a three-year gap for initial screening phases.*Every 5 years*- Screening **every 5 years** is inadequate for the management of chronic diabetes because **microvascular complications** can progress significantly within this timeframe.- Routine eye exams for diabetics require much more frequent monitoring than the general population due to the specific risks of **hyperglycemia-induced retinal damage**.

Q: A 48-year-old woman presents with a 6-month history of constipation, dry skin, weight gain of 8kg, and fatigue. Blood tests show TSH 42.1 mU/L (0.5-5.0), free T4 6.2 pmol/L (9-25), and positive thyroid peroxidase antibodies. What is the most appropriate initial levothyroxine dose for this patient?

50 micrograms once daily with dose increase every 3-4 weeks. ***50 micrograms once daily with dose increase every 3-4 weeks***- For adults under 65 without **cardiac disease**, an initial **Levothyroxine** dose of 50 mcg is appropriate to begin treatment and minimize adverse effects.- The dose should be **titrated** every 3-4 weeks based on **TSH levels** until the patient's TSH is within the target therapeutic range.*100 micrograms once daily*- Starting with a full replacement dose like **100 micrograms** might induce **iatrogenic hyperthyroidism** or cardiac strain in some patients, even without known cardiac disease.- This option does not mention the critical step of **gradual dose titration** and monitoring, which is essential for safe and effective management of hypothyroidism.*25 micrograms once daily with dose increase every 4 weeks*- A starting dose of **25 micrograms** is typically reserved for **elderly patients** or those with **pre-existing ischaemic heart disease** to prevent cardiac complications.- For a 48-year-old woman without known cardiac risk factors, this dose would be **sub-therapeutic** and delay achieving optimal thyroid function.*75 micrograms once daily*- **75 micrograms** is not a commonly recommended standard **initial starting dose** in clinical guidelines, which typically suggest 25, 50, or 100 mcg increments.- Like other single-dose options, it fails to include the essential component of **biochemical monitoring** and subsequent dose adjustments, which are crucial for effective treatment.*150 micrograms loading dose then 100 micrograms daily*- **Loading doses** of levothyroxine are specifically indicated only for life-threatening conditions like **Myxoedema Coma**, which is not the case for this patient.- Administering such a high initial dose to a stable patient with hypothyroidism could precipitate dangerous **thyrotoxic symptoms** or cardiac events.

Q: A 55-year-old woman with type 2 diabetes for 6 years presents for review. Her HbA1c is 64 mmol/mol despite maximal doses of metformin and a DPP-4 inhibitor. She has a BMI of 33 kg/m². She works as a lorry driver. eGFR is 68 ml/min/1.73m². Which is the most appropriate next step in her diabetes management?

Add an SGLT-2 inhibitor. ***Add an SGLT-2 inhibitor*** - **SGLT-2 inhibitors** are a preferred addition to triple therapy as they promote **weight loss** and have a very low risk of **hypoglycemia**, which is crucial for a **lorry driver** (Group 2 license). - The patient's **eGFR of 68 ml/min** is well within the acceptable range (typically >45 ml/min) for initiating this class of medication, which also offers **cardio-renal protective benefits**. *Add pioglitazone* - While effective for glycemic control, **pioglitazone** is associated with **weight gain** and fluid retention, which is undesirable given the patient's existing **obesity** (BMI 33). - It lacks the specific cardiovascular and renal benefits compared to SGLT-2 inhibitors, which are often prioritized in current guidelines. *Add a GLP-1 receptor agonist* - NICE guidelines typically suggest **GLP-1 receptor agonists** only if the **BMI is ≥35 kg/m²** or if insulin would have significant occupational implications due to weight. The patient's BMI is 33 kg/m². - Although she is a lorry driver, an **SGLT-2 inhibitor** is generally a more appropriate first choice in triple therapy intensification given her BMI and eGFR, due to its low hypoglycemia risk and weight loss benefits. *Add a sulphonylurea* - **Sulphonylureas** carry a significant risk of **hypoglycemia**, which poses a major safety risk and legal complication for a **lorry driver** under **DVLA regulations**. - This class often leads to **weight gain**, further complicating the management of her high BMI. *Switch to basal-bolus insulin regimen* - Transitioning to **insulin therapy** is premature as the patient has not yet exhausted appropriate **triple oral therapy** options and still has adequate renal function. - Insulin use requires strict **DVLA notification** and monitoring for commercial drivers due to the high risk of severe **hypoglycemic episodes**.

Q: A 64-year-old man with type 2 diabetes treated with metformin and gliclazide presents with a 4-month history of redness and swelling of his right foot. Examination reveals a warm, erythematous, swollen right foot with intact skin but a rocker-bottom deformity. Foot pulses are palpable. X-ray shows bone and joint destruction. What is the most likely diagnosis?

Charcot neuroarthropathy. ***Charcot neuroarthropathy*** - The combination of **type 2 diabetes**, a warm, swollen foot with **intact skin**, and a classic **rocker-bottom deformity** is pathognomonic for Charcot foot. - **Palpable pulses** and extensive **bone and joint destruction** on X-ray in the absence of an ulcer help differentiate this from infectious or ischemic processes. *Diabetic foot osteomyelitis* - Usually occurs secondary to a **chronic skin ulcer** which acts as a portal for infection, whereas this patient has **intact skin**. - While X-rays show bone destruction, the clinical presentation of a **midfoot collapse** over 4 months without systemic illness favors a neuropathic over an infectious etiology. *Acute gout* - Typically presents as an **acute, exquisitely painful** episode localized to a single joint, most commonly the **first metatarsophalangeal joint**. - It does not cause the characteristic **rocker-bottom deformity** or the chronic, progressive bone destruction seen in this patient's midfoot. *Septic arthritis* - Presents with **acute onset** of severe pain, fever, and systemic toxicity, which are inconsistent with a **4-month history**. - Joint aspiration would typically reveal a **high white cell count** and organisms, rather than the structural architectural collapse seen here. *Cellulitis with deep vein thrombosis* - **Cellulitis** causes localized redness and warmth but would not result in **radiographic bone destruction** or structural foot deformity. - **Deep vein thrombosis** presents with calf swelling and pain but does not explain the **chronic joint destruction** and palpable foot pulses documented.

Q: A 33-year-old woman with Graves' disease has been taking carbimazole 20mg once daily for 6 months. She now presents with a 2-day history of sore throat, fever, and general malaise. Examination shows temperature 38.4°C, pulse 92 bpm, and pharyngeal erythema. What is the most appropriate immediate management?

Stop carbimazole immediately and arrange urgent full blood count. ***Stop carbimazole immediately and arrange urgent full blood count***- **Agranulocytosis** is a rare but life-threatening side effect of **carbimazole**, and a sore throat with fever in a patient on this medication must be treated as a medical emergency.- The drug must be **stopped immediately**, and an **urgent Full Blood Count (FBC)** is required to check for a **neutrophil count** (typically <0.5 x 10⁹/L in agranulocytosis).*Continue carbimazole and prescribe oral penicillin V for pharyngitis*- Prescribing antibiotics without checking the blood count is dangerous as it may mask **sepsis** while the underlying **bone marrow suppression** continues.- Carbimazole must not be continued if there is any clinical suspicion of **agranulocytosis** until the FBC result is known.*Reduce carbimazole dose to 10mg daily and review in 1 week*- **Agranulocytosis** is an idiosyncratic reaction, not strictly dose-dependent; merely reducing the dose does not eliminate the risk of fatal infection.- Waiting one week for review is inappropriate as **neutropenic sepsis** can progress rapidly and lead to death within days.*Continue carbimazole, arrange routine blood tests, and prescribe symptomatic treatment*- Routine blood tests take too long; **urgent medical attention** is required to prevent severe infection in an immunocompromised patient.- Symptomatic treatment alone fails to address the potentially lethal drop in **white blood cells** caused by the medication.*Stop carbimazole and commence propylthiouracil as alternative antithyroid drug*- **Propylthiouracil** (PTU) also carries a significant risk of agranulocytosis and frequently shows **cross-reactivity** with carbimazole-induced bone marrow suppression.- Switching to another thionamide is contraindicated if the patient has experienced a severe reaction like agranulocytosis with the first drug.

Question 1

A 32-year-old woman presents with palpitations and anxiety. Examination reveals a fine tremor, warm moist skin, and a smooth, non-tender goitre. Thyroid function tests show TSH <0.05 mU/L (0.5-5.0), free T4 32 pmol/L (9-25), free T3 12.4 pmol/L (3.5-6.5). TSH receptor antibodies are positive. She is planning pregnancy in the next 6 months. What is the most appropriate initial management?

Accepted Answer

Propylthiouracil

Answer

Carbimazole titration regime

Answer

Carbimazole block and replace regime

Answer

Radioiodine therapy

Answer

Propranolol alone

Question 2

A 69-year-old man with type 2 diabetes presents to the emergency department with confusion. His wife reports he has had diarrhoea and vomiting for 4 days. On examination, he is drowsy but rousable, blood pressure 95/60 mmHg, heart rate 105 bpm. Capillary glucose is 42.8 mmol/L. Blood tests show sodium 152 mmol/L, urea 18.4 mmol/L, creatinine 185 µmol/L, serum osmolality 348 mOsm/kg. Venous blood gas shows pH 7.36, ketones 0.4 mmol/L. What is the diagnosis?

Accepted Answer

Hyperosmolar hyperglycaemic state

Answer

Diabetic ketoacidosis

Answer

Euglycaemic diabetic ketoacidosis

Answer

Acute kidney injury with hyperglycaemia

Answer

Mixed DKA and HHS

Question 3

What is the recommended frequency for diabetic retinopathy screening in adults with type 1 or type 2 diabetes who have no evidence of retinopathy?

Accepted Answer

Annually

Answer

Every 6 months

Answer

Every 2 years

Answer

Every 3 years

Answer

Every 5 years

Question 4

A 48-year-old woman presents with a 6-month history of constipation, dry skin, weight gain of 8kg, and fatigue. Blood tests show TSH 42.1 mU/L (0.5-5.0), free T4 6.2 pmol/L (9-25), and positive thyroid peroxidase antibodies. What is the most appropriate initial levothyroxine dose for this patient?

Accepted Answer

50 micrograms once daily with dose increase every 3-4 weeks

Answer

100 micrograms once daily

Answer

25 micrograms once daily with dose increase every 4 weeks

Answer

75 micrograms once daily

Answer

150 micrograms loading dose then 100 micrograms daily

Question 5

A 23-year-old woman with type 1 diabetes for 9 years presents to the emergency department with vomiting and abdominal pain. Capillary glucose is 24.6 mmol/L, ketones 4.2 mmol/L. Venous blood gas shows pH 7.18, bicarbonate 11 mmol/L, potassium 5.8 mmol/L. What is the correct initial fluid and potassium replacement strategy?

Accepted Answer

0.9% sodium chloride without potassium chloride at 1000 ml/hour initially

Answer

0.9% sodium chloride with 40 mmol/L potassium chloride at 500 ml/hour

Answer

0.45% sodium chloride with 40 mmol/L potassium chloride at 500 ml/hour

Answer

Hartmann's solution without potassium at 500 ml/hour

Answer

0.9% sodium chloride with 20 mmol/L potassium chloride at 1000 ml/hour

Question 6

A 55-year-old woman with type 2 diabetes for 6 years presents for review. Her HbA1c is 64 mmol/mol despite maximal doses of metformin and a DPP-4 inhibitor. She has a BMI of 33 kg/m². She works as a lorry driver. eGFR is 68 ml/min/1.73m². Which is the most appropriate next step in her diabetes management?

Accepted Answer

Add an SGLT-2 inhibitor

Answer

Add pioglitazone

Answer

Add a GLP-1 receptor agonist

Answer

Add a sulphonylurea

Answer

Switch to basal-bolus insulin regimen

Question 7

A 64-year-old man with type 2 diabetes treated with metformin and gliclazide presents with a 4-month history of redness and swelling of his right foot. Examination reveals a warm, erythematous, swollen right foot with intact skin but a rocker-bottom deformity. Foot pulses are palpable. X-ray shows bone and joint destruction. What is the most likely diagnosis?

Accepted Answer

Charcot neuroarthropathy

Answer

Diabetic foot osteomyelitis

Answer

Acute gout

Answer

Septic arthritis

Answer

Cellulitis with deep vein thrombosis

Question 8

A 17-year-old girl presents to the emergency department with a 3-week history of polyuria, polydipsia, and 6kg weight loss. She appears thin and mildly dehydrated. Blood glucose is 18.2 mmol/L. Urinalysis shows glucose 3+ and ketones 1+. Venous blood gas shows pH 7.38, bicarbonate 22 mmol/L. What is the most appropriate initial management?

Accepted Answer

Start basal-bolus subcutaneous insulin regimen and provide diabetes education

Answer

Give stat dose of intramuscular insulin and reassess in 2 hours

Answer

Commence oral metformin 500mg twice daily

Answer

Admit for observation and repeat blood tests in 6 hours

Answer

Start variable rate intravenous insulin infusion immediately

Question 9

A 26-year-old woman with type 1 diabetes is 16 weeks pregnant. Her pre-pregnancy HbA1c was 51 mmol/mol. She monitors blood glucose closely with targets of 5.3 mmol/L fasting and <7.8 mmol/L 1-hour post-prandial. Despite good compliance, she has experienced three episodes of severe hypoglycaemia requiring assistance in the past 4 weeks. Her current insulin regimen is insulin detemir 18 units morning and 14 units evening, with insulin aspart before meals. What change in her management approach is most appropriate?

Accepted Answer

Relax glucose targets to fasting <6.0 mmol/L and 1-hour post-prandial <8.5 mmol/L to reduce hypoglycaemia frequency

Answer

Reduce basal insulin doses by 10-20% and accept slightly higher fasting glucose readings to prevent hypoglycaemia

Answer

Switch to continuous subcutaneous insulin infusion (pump therapy) to reduce hypoglycaemia risk

Answer

Continue current regimen as hypoglycaemia is expected in first and second trimester with tight control

Answer

Add continuous glucose monitoring with hypoglycaemia alerts but maintain current targets and insulin doses

Question 10

A 33-year-old woman with Graves' disease has been taking carbimazole 20mg once daily for 6 months. She now presents with a 2-day history of sore throat, fever, and general malaise. Examination shows temperature 38.4°C, pulse 92 bpm, and pharyngeal erythema. What is the most appropriate immediate management?

Accepted Answer

Stop carbimazole immediately and arrange urgent full blood count

Answer

Continue carbimazole and prescribe oral penicillin V for pharyngitis

Answer

Reduce carbimazole dose to 10mg daily and review in 1 week

Answer

Continue carbimazole, arrange routine blood tests, and prescribe symptomatic treatment

Answer

Stop carbimazole and commence propylthiouracil as alternative antithyroid drug

Endocrinology & Diabetes — MCQs

Endocrinology & Diabetes — MCQs

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