1.

In hypercalcaemia secondary to Primary Hyperparathyroidism, which of the

following are true?
a. The commonest cause is Parathyroid adenoma
b. Presence of gall bladder calculi
c. Serum phosphate is often increased
d. The PTH (Parathyroid Hormone) is low/undetectable
e. Gastrointestinal absorption of calcium is normal

2. The commonest clinical manifestation of Primary Hyperparathyroidism is:

a. Renal stone disease
b. Bone disease
c. Peptic ulceration
d. Constipation
e. Polyuria

3. A sixty year old man presents with headache and increased sweating. On
examination he has large hands and the facial features are exaggerated with
large nose, prominent jaw and thick lips.
In this patient which of the following may be used as a screening test?
a. Growth hormone level
b. Glucose Tolerance Test
c. Prolactin level
d. Plasma Insulin-like Growth Factor levels
e. Serum calcium

4. A 25 year old female presented with periodic episodes of severe headache,

nausea, vomiting and severe sweating with loss of consciousness for a couple
of minutes but no convulsions and no visual disturbance. Her grandfather and
her cousin who is 30 years old are both hypertensive. On examination: BP
200/140, HR 100/min, RR 18/min afebrile. BMI 20kg/m2. Rest of the systemic
examination was normal.

Which of the following is a possible cause of her hypertension?

a. Thyrotoxicosis
b. A suprarenal mass on abdominal CT scan
c. Hyperparathyroidism
d. Hypothyroidism
e. Cushing’s syndrome
5. A 25 year old lady presented with severe fatigue and inability to perform her
usual daily duties. Examination was remarkable for a thin built female with
dark mucus membranes and hand creases.
This lady’s disease is associated with:
a. Hypotension
b. Metabolic alkalosis
c. Hyperglycemia
d. Hypokalemia
e. Abdominal distension

6. A 47 year old lady presented with lethargy, weakness and weight loss, she has
history of intermittent diarrhea and arthralgia. She had postpartum
haemorrhage and hysterectomy 15 years ago and was unable to breast feed
her baby. She looked rather pale and thin, BP 90/50 examination otherwise
unremarkable.
What is the most likely diagnosis?
a. Hypothyroidism
b. Panhypopituitarism
c. Ulcerative colitis
d. Hypoparathyroidism
e. Abdominal tuberculosis

7. A 26-years old lady presented to the ER feeling extremely unwell, BP 90/50

pulse 100/min, nauseous, blood glucose found to be 60mg/dl. Her family
informed the doctor that she has some problems with her glands and she
stopped her medications without consulting her doctor.
Her investigations came back with a free T4 of 10 (12-22) pmol/l & random
cortisol of 70 (100-450) nmol/l. After initial resuscitation, how are you going to
manage her?
a. Start oral thyroxine 100 mg od
b. Start intravenous hydrocortisone 100mg 6 hourly
c. Start intravenous hydrocortisone and thyroxine at the same time
d. Wait for 9:00 am cortisol before giving any treatment
e. Send her for a pituitary MRI

8. A 30 years old patient presented with fatigue, polyuria & polydipsia for 2
weeks. His blood glucose 360 mg/dl. His father was diagnosed with Type2
diabetes 3 years ago. Which of the following is true:
a. Presence of urine ketones confirms type 1 diabetes
b. Most likely he has Type 2 diabetes
c. A low C-peptide level would lead to a diagnosis of type1 Diabetes
d. Another blood glucose reading is needed to confirm a diagnosis of
diabetes mellitus
e. His age is against the diagnosis of type1 Diabetes
9. A 40 years old female patient (weight is 68 kg) is diagnosed with diabetes, she
has an uncle with diabetes diagnosed at the age of 60 . In her first presentation
she was in DKA (diabetic ketoacidosis). She is more likely to be type1 Diabetes
because of:
a. Her family history
b. Relatively young age of onset
c. Her weight
d. Her presentation in DKA
e. Being a female

10. Ali is a 70 yr old man with T2DM for 6 years. He is on Metformin and
sulphonylurea. Investigations done last month showed HbA1c of 7.9%. He
presented to the casuality with fever, refusal to eat and productive cough.
Clinically he was deeply comatose, dehydrated, BP 90/60.
Investigations showed Serum osmolarity of 320 mOsm/Kg (280-300) and a
Random Blood Sugar of 580 mg/dl. No ketones in the urine.
Which of the following is the next appropriate step in his management?
a. Commence broad spectrum antibiotics and observe
b. Give Insulin immediately
c. Delay antibiotics till you get the result of sputum culture
d. Give a bolus dose of intravenous bicarbonate
e. Set up an IV line and run 2 litres of Normal Saline

11. A 60 yr old lady brought to the ER with respiratory distress. She had sustained
trauma and fracture to her left lower limb. She had long standing diabetes
complicated by retinopathy and nephropathy. The family noticed her to be
rather depressed over the last month and was complaining of constipation.
O/E mentally slow, obese with coarse features, dry skin, patchy vitiligo,
laboured breathing, RR 33/min, cold extremities temp 35°C, Pulse 50/min sinus
rhythm. Arterial Blood Gases (ABG): PH 7.2 (7.34-7.44), PO2 60 mmHg (90-100),
PCO2 70 mmHg (35-45), HCO3 28 mmHg (22-26).
Which of the following about this patient is true?
a. She has thyroid storm
b. She has Type l Respiratory Failure
c. Start intravenous antibiotics, IV fluids and observe
d. Start high flow Oxygen by facial mask
e. Admit to ICU, consider assisted ventilation and IV thyroxine
12. A 22 years old male presents with weight loss and palpitations. People told him
his eyes were getting very prominent. He appeared to be anxious and shaky.
Pulse 120/min regular. Thyroid slightly enlarged. TFT:
TSH 0.02 nmol/l (0.5-5). FT4 200 nmol/l (60-145). FT3 10 nmol/l (1-3)
Which of the following is true about this patient?
a. He has Graves’ disease
b. He has hypothyroidism and needs thyroxine
c. Repeat the TFT
d. Refer for surgery
e. Refer for radio-iodine treatment
13. A 35 year old lady presents with progressive headache and intermittent blurring
of vision, she gives a 6 month history of amenorrhoea and galactorrhoea. Clinical
examination was unremarkable apart from a mild bitemporal upper
quadrantopia. Laboratory test revealed normal thyroid function test and
random cortisol. Serum prolactin however was elevated at 12000 mu/L [normal
range <360]. MRI of pituitary fossa was consistent with a pituitary
macroadenoma pressing on the optic chiasm and extending into the right
cavernous sinus. The most appropriate initial management is:

a. Prescribe pain killers, send patient to ophthalmology services for visual

field charting, and plan to reassess in 2-4 weeks time with repeat
biochemical tests beforehand.
b. Refer for immediete neurosurgical opinion.
c. Start cabergoline 1 mgm twice a week, advice to return promptly if she
develop severe headache or visual disturbance, reassess in 2 weeks.
d. Send for consideration of pituitary radiotherapy.
e. Arrange for full insulin tolerance test for appropriate evaluation of growth
hormone and cortisol axis function.
14. A 29 year old lady, seeking fertility treatment conceived spontaneously while
awaiting investigations. At 18 weeks gestation she presented with headaches
of fluctuating severity. She was found to have galactorrhoea and elevated
prolactin levels at 1300 mu/L [<360], visual field charting was unremarkable. All
basal pituitary functions tests where normal. MRI revealed enlarged pituitary
gland 2.2 cm in diameter, smooth, touching on but not stretching the optic
chiasm.
The most appropriate management plan

a. Monitor during rest of pregnancy with regular visual field charting and
advise patient to report back immediately if severe headache or visual
symptoms.
b. This is likely a prolactin secreting pituitary macro-adenoma, arrange
neuro-surgical referral.
c. Consider termination of pregnancy to reduce chances of progression of
pituitary adenoma.
d. Start bromocriptine and review in 4 weeks.
e. Start cabergoline and review in 4 weeks.

15. A 36 years old mechanic attends his physician complaining of headaches, fatigue
and thirst of 3 month duration; he smokes 30 cigarettes/day. Examination
revealed a heavy-built, overweight muscular young man with big thick hands and
rather coarse features, BP 210/110, pulse 76/min regular, clinical examination
was otherwise unremarkable including CNS and visual fields examination. CBC
and urea, creatinine and electrolytes were normal. Random blood glucose was
260 mgm/dl, ECG shows left ventricular hypertrophy. The physician requests
further studies: TSH 4.5 [0.35 -5.0], FT4 13 nmol/l [12 – 22], Random GH < 0.01
mcg/dl.
The most appropriate management stepis:

a) Arrange oral glucose tolerance test to confirm diagnosis of diabetes.

b) Start antihypertensive medication and metformin, give life style advice
and refer to diabetes nurse and dietician.
c) Arrange oral glucose tolerance test with glucose and GH series to
investigate for the possibility of acromegally.
d) Advice to stop smoking and review in 2 weeks to confirm persistent
hypertension, and to recheck blood glucose.
e) Arrange a CT brain to exclude a space occupying lesion.
16. A 74 years old lady presents with history of progressive weight loss and
intermittent cough. She complained of excessive fatigue and general weakness.
Examination revealed a thin lady with generalized hyperpigmentation. She has
finger clubbing and wasting of hand muscles. Clinical examination was otherwise
unremarkable. Serum Na 140, K 2.7, Urea & creatinine and LFTs were normal. Hb
9.3, MCV 87.0 platelets 245, ESR 98. The physician suspects a lung neoplasm with
Cushing’s syndrome due to ectopic ACTH secretion.
Which of the following is most supportive of his suspicion of ectopic ACTH

secretion?

a) Abnormal chest X-ray and raised random plasma cortisol level.

b) Elevated 24-hour urine cortisol excretion and failure of suppression on
high-dose dexamethason test [2mgm qds for 48 hours].
c) Failure of suppression to overnight dexamethasone [1mgm] test and
failure of suppression to low-dose dexamethasone test [0.5mgm qds for
48 hours].
d) Failure of suppression to overnight dexamethasone [1mgm] test and
adequate suppression to high-dose dexamethasone test [2 mgm qds for
48 hours].
e) Elevated ACTH and low random cortisol level.

17. 28 year old lady presents with palpitations. She has been recovering from a
febrile illness with dry cough and shortness of breath. She has no past medical
history of significance. She looked anxious and stressed with warm sweaty
hands and tremors, she has lid retraction but no other eye signs, examination
of the neck revealed mild tenderness over the thyroid area but no palpable
goitre. TSH <0.05 mu/l [0.35-5.0] and FT4 36 nmol/l [12-22].
Which investigation will help confirm diagnosis and inform therapy?
a. Measure serum level of thyroid peri-oxidase antibody.
b. Ultrasound scan of the thyroid.
c. Measure FT3 level and TSH receptor antibody levels.
d. Radio-isotope thyroid uptake scan.
e. Colour-flow Doppler Ultrasound of thyroid.
18. A young married woman of child bearing age presents with history of insomnia,
Tiredness and palpitations. She has intermittent diarroehia and has lost 4 kg of
weight in recent weeks. She gave a history of amenorrhea for 3 month
Examination revealed tachycardia, tremors, obvious exophthalmose and
opthalmoplegia, and a diffuse goitre with audible bruits. Biochemical tests
confirmed thyrotoxicosis.

Which of the following statements is most appropriate?

a) Ant-thyroid drugs cross the placenta, should be avoided during pregnancy,

patient should be treated symptomatically with propronalol.
b) Thyroid surgery is the best therapeutic approach for her and should be done
as soon as possible.
c) Radio-iodine therapy can only be considered in the second trimester of
pregnancy.
d) Propylthiouracil is preferred during pregnancy because it is safer with lower
teratogenicity compared to carbimazole.
e) The presence of Graves’s opthalmopathy is an absolute contraindication to
radio-iodine therapy.
19. A 26yr old lady brought to ER by the family because of confusion and
drowsiness. She has type 1 DM on insulin, and diagnosed with malaria. She has
recently stopped her insulin injections because she had poor oral intake ,
vomiting and feared hypoglycemia.

The following statements are true regarding this patient:

a) DKA is unlikely if focal neurological signs are present

b) CT scan of the brain is essential
c) The patient should be given a glucose drink orally if hypoglycemia is
established
d) Potassium supplement should be given if DKA is diagnosed
e) Bicarbonate should be given if blood pH less than 7.34.
20. A 60 yr. old lady brought to the ER with respiratory distress. She had sustained
trauma and fracture to her left lower limb. She had long standing diabetes with
complications of retinopathy, nephropathy and CKI. The family noticed her to
be rather depressed over the last month and was complaining of constipation.
 O/E pt. obtunded, obese with coarse features, dry skin, labored breathing
RR 33/min, cold extremities temp 35
 PR 50/min sinus rhythm
The following are true regarding this patient:

a) Carpal tunnel syndrome is not a recognized feature of this condition

b) Pleural effusion may occur
c) Hypernatremia can be found
d) Type 2 respiratory failure can occur in such conditions
e) Pretibial myxedema is characteristic
21. A 25yr old brought to the ER with confusion and disorientation. She is known to
have thyroid disease and is not taking her medication. She was booked for
dental extraction and was delayed because there was infection of the tooth.
She was given antibiotics, but became worse.
O/E she was confused GCS of 5. febrile 39C, HR 140/min, in AF, tremors of the
hands and Graves Ophthalmopathy.
The following are true regarding this patient
a. IV beta blockers are contraindicated.
b. Heart failure is an unexpected complication
c. Eye changes usually disappear when the TFT return to normal
d. Propylthiouracil blocks the conversion of T4 to T3
e. Infection may not be the cause of this condition

22. A 35yr old lady, presented with severe fatigue and inability to perform her usual
daily duties. Examination was remarkable for a thin built female with dark mucus
membranes and hand creases.
This lady’s disease may be associated with:-

a) Hypertension
b) Hyperglycemia
c) Abdominal pain
d) Hypokalemia
e) Tuberculosis is unlikely to cause this condition

23. An elderly pt., diabetic for 21yrs was brought to the ER by her family comatosed.
She recently complained of dysuria and refused feeding. Her RBS was 600mg/dl,
urea 170, creatinine 2.4. Na 146, K 3.4, ABG PH 7.3, PO2 88, PCO2 29, HCO 20.
Urine showed 1+ acetone.

The following are true of this patient:

a) The patient requires high doses of insulin
b) She will need heparin to guard against DVT.
c) She has developed ESRD secondary to DM nephropathy
d) She has DKA needing a lot of fluid
e) Rapid drop of the blood sugar is mandatory

24. A 40 year old lady attended for routine check. She was well with no symptoms
to report. Systems review was normal. Wt 84kg. BMI 29, Bp 140/85, pulse
76/minute clinical examination unremarkable. Investigations: CBC, RFT, LFT
were normal .Random blood glucose was 202 mg/dl. What would you do next?
a) Ask her to return for check after three months.
b) Prescribe diet and exercise program.
c) Prescribe metformin.
d) Arrange for fasting blood sugar
e) Start Glibenclamide
25. A 53 year old gentleman under investigation for loss of libido, presented to casualty
with acute severe headache, nausea, vomiting and blurring of vision. Clinical
examination revealed bitemporal hemianopia, there was no photophobia or neck
stiffness. The most likely diagnosis is:-

a) Subarachnoid hemorrhage.
b) Severe migraine.
c) Pituitary apoplexy
d) Occipital infarct
e) Optic neuritis

26. A 36 year old lady presented with recent onset intermittent visual blurring, she
gave a few month history of headache, amenorrhea and profuse nocturnal
sweating .She has recently started treatment for hypertension. She was
clinically well, have coarse features with prognathism, BP 160/95, pulse
80/minute, eye testing revealed bitemporal upper quadrantanopia.
Appropriate tests to help establish diagnosis include:

a) 24 Hour urine catecholamine.

b) Oral glucose tolerance test and IGF-1.
c) CT scan of brain.
d) Random growth hormone
e) MRA

27. A 50 years old lady referred with history of progressive weight gain, she was also
concerned about multiple skin bruises. She struggled to rise from chair onto the
examination couch, BP 160/100, Weight 87, BMI 32, there was central adiposity
with multiple abdominal purple stretch marks. Which of the following test will
help establish diagnosis?

a) Short Synacthen test.

b) 24 Hours urinary free cortisol
c) Insulin tolerance test.
d) Serum testosterone.
e) Serum T3 ,T4 & TSH.
28. A 57 years old lady presented with lethargy, weakness and wt loss, she has
history of intermittent diarrhea and arthralgia. She had a hysterectomy 15
years earlier following postpartum hemorrhage after birth of her 6th child. She
felt bad since because she was unable to breastfeed her baby as she had no
breast milk, she continued to feel low with multiple vague symptoms. She
looked rather pale and thin, BP 90/50 examination otherwise unremarkable.
Investigations: Hb 9.7, WBC 3.4, Plts 300, ESR 98. Na 128, K 4.0, Urea 40. creatinine
0.9, Bil 0.6, Alb 3.2 , T protein 5.7, AST 40, ALT 43. Alk phos 100.
What is the most likely diagnosis?

a) Hypothyroidism.
b) Coeliac disease
c) Addisons disease.
d) Hypopituitarism.
e) Abdominal tuberculosis

29. A 35 year old lady presented with progressive headache, headache is constant,
she takes regular paracetamol, but often wakes up with headache in the
morning, and she has been trying for a baby since she got married 3 years ago.
Clinical examination revealed bilateral galactorrheoa, examination was
otherwise unremarkable including normal visual fields. Serum prolactin was
elevated at 12000 (<360), MRI of pituitary fossa showed a pituitary tumor with
supra-cellar extension stretching the optic chiasm.

The most appropriate step in management is:

a) Immediate referral to a neurosurgeon.

b) Start oral cabergoline.
c) Start IV metclopromide
d) Waite & see, repeat MRI in 8 weeks
e) Start oral thyroxine 100 mcgm od.

30. A 30 year old lady presented with symptoms suggestive of thyrtoxicosis, she
was clinically toxic with a goiter, and TSH was suppressed with elevated FT4 &
FT3. When you examine her eyes you will keep in mind that:

a) Lid lag suggest toxic nodular goiter.

b) Lid retraction indicates Graves disease.
c) Proptosis suggests a toxic thyroid nodule.
d) Ophthalmoplegia and exophthalmos indicate Graves disease.
e) Peri-orbital puffiness indicates subacute thyroiditis.
31. Primary hyper parathyroidism as opposed to non-metastatic hypercalcaemia of
malignancy is favored by:
a) Polydipsia & polyuria
b) Metabolic acidosis
c) Constipation
d) Acute onset
e) Presence of subperiosteal erosion

32. Regarding oral hypoglycemic agents:

a) Glitazones are usually used as monotherapy.

b) Metformin causes hypoglycemia.
c) Glibenclamide is safe in elderly patients.
d) In type II DM oral hypoglycemic agents can not be used in combination with
Insulin.
e) Weight gain is a side effect of Sulphonylureas.

33. A 37 year old man presented to the outpatient with history of recurrent
hypoglycemia and hyperpigmentation, Addison’s disease is confirmed by:
a) Random plasma cortisol level
b) Presence of postural hypotension
c) Short ACTH stimulation test
d) Low dose dexamethasone suppression test
e) 24 hours urinary free cortisol level

34. A 23 year old female patient presented to A&E with fever and sore throat
associated with red painful non-itchy nodules over both shins. The most likely
diagnosis is:

a) Psoriasis
b) Eczema
c) Erythema nodusum
d) Erythema multiforme
e) Subcutaneous nodules due to rheumatic fever
35. A 50 years old lady referred with history of progressive weight gain, she was also
concerned about multiple skin bruises. She struggled to rise from chair onto the
examination couch, BP 160/100, Weight 87, BMI 32, there was central adiposity with
multiple abdominal purple stretch marks.

Which of the following test will help establish diagnosis?

a) Short Synacthen test.

b) 24 HR urinary free cortisol
c) Insulin tolerance test.
d) Serum testosterone.
e) Random cortisol level.
36. A 57 years old lady presented with lethargy, weakness and wt loss, she has history of
intermittent diarrhea and arthralgia.. She had a hysterectomy 15 years earlier
following postpartum hemorrhage after birth of her 6th child. She felt bad since
because she was unable to breastfeed her baby as she had no breast milk, she
continued to feel low with multiple vague symptoms. She looked rather pale and thin,
BP 90/50 examination otherwise unremarkable.

Investigations: Hb 9.7, WBC 3.4, Plts 300, ESR 98. Na 128, K 4.0, Urea 40. creatinine 0.9,

Bil 0.6, Alb 3.2 , T protein 5.7, AST 40, ALT43. Alk phos 100.

What is the most likely diagnosis?

f) Systemic lupus erythematosis.

g) Coeliac disease
h) Addisons disease.
i) Hypopituitarism.
j) Tropical sprue

37. A 35 years old lady presented with progressive headache, headache is constant, she
takes regular paracetamol, but often wake up with headache in the morning, she has
been trying for a baby since she got married 3 years ago. Clinical examination revealed
bilateral galactorrheoa, examination was otherwise unremarkable including normal
visual fields. Serum prolactin was elevated at 12000 (<360), MRI of pituitary fossa
showed a pituitary tumor with supra-cellar extension stretching the optic chiasm.

The most appropriate management step is:

f) Immediate referral to a neurosurgeon.

g) Start oral cabergoline.
h) Start IV metclopramide
i) Waite & see, repeat MRI in 8 weeks
j) Start oral thyroxine 100 mcgm od.

38. A 30 years old lady presents with symptoms suggestive of thyrtoxicosis, she was
clinically toxic with a goiter, TSH was suppressed with elevated FT4 & FT3.

When you examine her eyes you will keep in mind that:

f) The presence of lid lag suggest toxic nodular goiter.

g) The presence of lid retraction indicates Graves’s disease.
h) The presence of proptosis suggests a toxic thyroid nodule.
i) The presence of opthalmoplegia and exophthalmoses indicate Graves’s disease.
j) Peri-orbital puffiness indicates subacute thyroiditis.
39. Thyrotoxicosis due to Grave’s disease:
a. Commoner in males
b. A very large thyroid is always present
c. Diagnosis is by raised T3, raised T4 and raised TSH.
d. Diarrhea can lead to malabsorption and severe weight loss.
e. Radioiodine is used as first line management

40. Which one of the following medications causes hypothyroidism?

a. Fluoxetine
b. Olanzapine
c. Chlorpromazine
d. Lithium carbonate
e. Carbamazepine

41. Increase in weight , osteoprosis and coarse skin is a feature of

a. Acromegally
b. Myxedema
c. Graves disease
d. Cushing syndrome
e. Hypopitutarism

42. Which of the following is a feature of the following is a feature of primary

hypothyroidism:
a. low TSH level
b. brisk ankle jerk
c. tachycardia
e. loss of axillary & pubic hair in females

43. Targets of good metabolic control in diabetes mellitus include all of the following
except:
a. Fasting blood glucose < 120 (mg/dl)
b. Low density lipoprotein <100(mg/dl)
c. Body mass index 34
d. Hb A1C 6%
e. Serum uric acid 4.5mg/dl

44. Radioiodine treatment in goitre is contraindicated in :

a. Young age
b. Recurrent toxic goitre
c. Retrosternal goitre
d. patients on B-blockers
e. Atrial fibrillation
45. Hypercalcemia occurs in:
a. Addison’s disease
b. Malabsorption syndrome
c. Osteomalacia
d. Chronic renal failure
e. Pseudohypoparathyroidism

46. A 40 years old lady presented with recent onset intermittent visual blurring, she gave a
few month history of headache, amenorrhea and profuse nocturnal sweating .She has
recently started treatment for hypertension. She was clinically well BP 160/95, pulse
80/minute; she had coarse features with prognathism and bitemporal hemanopia.
The appropriate test to help establish diagnosis is:
A. 24 Hour urine catecholamine.
B. Oral glucose tolerance test and IGF-1.
C. CT scan of brain.
D. Random growth hormone
E. Chest x-ray and Mantoux test

47. A 50 years old lady referred with history of progressive weight gain, she was also
concerned about multiple skin bruises. She struggled to rise from chair onto the
examination couch, BP 160/100, Weight 87, BMI 32, there was central adiposity with
multiple abdominal purple stretch marks.
Which of the following tests will help establish diagnosis?
a) Short Synacthen test.
b) 24 HR urinary free cortisol
c) Insulin tolerance test.
d) Serum testosterone.
e) Random cortisol level.

48. A 53 years old lady presented with lethargy, weakness and weight loss, she has
history of intermittent diarrhea and arthralgia.. She had a hysterectomy 15
years earlier following postpartum hemorrhage after birth of her 6th child. She
felt bad since, because she was unable to breastfeed her baby, she continued
to feel low with multiple vague symptoms. She looked rather pale and thin, BP
90/50 examination otherwise unremarkable.What is the most likely diagnosis?
a) Systemic lupus erythematosis.
b) Coeliac disease
c) Addisons disease.
d) Hypopituitarism.
e) Tropical sprue
49. A 19 years old lady was found collapsed at home and brought to casualty, she
was not feeling too good the night before with fatigue, nausea and episodes of
vomiting, she received an anti-emetic injection and malaria tablets and went to
bed. She was drowsy but responsive, mouth was dry, with dry skin, and her
breathing was rapid and deep, pulse 112 / minute. BP 100/55.
Investigations: RBG 440mg/dl, Creatinine 1.2, urea 67, Na 129, K 4.0, Hb 13.0, WBC
13.9, Platelets 160000/ml PH 7.00, HCO3 13 mmol/l, PO2 95%, PCO2 40.

The following are appropriate steps in immediate management except:

a) Assess and manage airway, breathing and circulation.

b) Start intravenous saline infusion.
c) Start intravenous insulin infusion.
d) Give intravenous bicarbonate.
e) Regular monitoring.

50. A 35 years old lady presented with progressive headache, which is constant, she takes
regular paracetamol, but often wakes up with headache in the morning, and she has
been trying for a baby since she got married 3 years ago. Clinical examination revealed
bilateral galactorrheoa, examination was otherwise unremarkable including normal
visual fields. Serum prolactin was elevated at 12000 (Normal<360), MRI of pituitary
fossa showed a pituitary tumor with supra-cellar extension stretching the optic
chiasm. The most appropriate management step is:
A. Immediate referral to a neurosurgeon.
B. Start oral cabergoline.
C. Start IV metclopramide
D. Wait & see, repeat MRI in 8 weeks
E. Start oral thyroxine 100 µgm once daily

51. A 30 years old lady presents with symptoms suggestive of thyrotoxicosis, she
was clinically toxic with a goiter, and TSH was suppressed with elevated FT4 &
FT3.When you examine her eyes you will keep in mind that:

a. The presence of lid lag suggest toxic nodular goiter.

b. The presence of lid retraction indicates Graves’s disease.
c. The presence of proptosis suggests a toxic thyroid nodule.
d. The presence of opthalmoplegia and exophthalmous indicate Graves’s
disease.
e. Peri-orbital puffiness indicates subacute thyroiditis.
52. A 76 years old lay with history of type2 diabetes and hypertension, presented
with recurrent funny turns. Her family described episodes of extreme tiredness,
when she becomes cold and clammy then sleepy; she spontaneously recovers
after a few hours. During one of these episodes she was noted to have right leg
weakness but this subsequently improved, on another occasion she developed
brief jerky movements of right upper limb but there was no tongue biting or
urinary incontinence. She was maintained on Aspirin 75mg, glibenclamide 5 mg,
losartan 50 mg and atenolol 50 mg. She looked well BP 150/85, pulse 70 /minute
irregularly irregular, carotid arteries were normal; examination of the CNS,
chest, cardiovascular and abdominal systems was unremarkable.

Investigations: Na 134, K 4.1, Urea 67, creatinine 1.9, Hb 11, WBC 5.0, Platelets
200000/ml

The most appropriate initial management steps include:

a) Request MRI scan of the brain.

b) Stop aspirin
c) Stop Glibenclamide
d) Request an EEG
e) Start sodium valproate.

53. A 25-year old female patient presented with weight loss, lethargy and black
buccal pigmentation, her BP was 90/60 mmHg and serum K level is 5.6 mEq/L.
the most likely diagnosis is:
a) Chronic renal failure
b) Addison's disease
c) Panhypopituitarism
d) Chronic steroid therapy
e) Decompensated liver disease

54. A 40 years old lady attended for routine check. She was well with no
symptoms to report. Systems review was normal. Wt 84kg. BMI 29, Bp 140/85,
pulse 76/minute, clinical examination unremarkable.
Investigations: CBC, RFT, LFT were normal .Random blood glucose was 202 mg/dl.
What would you do next?
a. Ask her to return for check up next year..
b. Prescribe diet and exercise program.
c. Prescribe metformin
d. Arrange for fasting blood sugar
e. Start Glibenclamide
55. In hypercalcaemia secondary to primary hyperparathyroidism, which of the
following are true?
a) The cause in 80% of patients is parathyroid hyperplasia
b) The PTH (Parathyroid Hormone) may be in the normal range
c) The presence of renal calculi makes the diagnosis unlikely
d) Serum phosphate is often increased
e) Gastrointestinal absorption of calcium is normal

56. A 53 year old gentleman under investigation for loss of libido, presented to
casualty with acute severe headache, nausea, vomiting and blurring of vision.
Clinical examination revealed bitemporal hemianopia, there was no
photophobia or neck stiffness. The most likely diagnosis is:

a. Subarachnoid hemorrhage
b. Severe migraine
c. Pituitary apoplexy
d. Occipital infarct
e. Optic neuritis

57. A 19 year old man with T1DM was brought to the casualty with DKA. He had
stopped taking his insulin for 2 days. Which, of the following is appropriate
regarding his initial management:
a) Give long acting insulin
b) Start Metformin
c) Give 2 liters of normal saline in the first hour
d) Give K supplement
e) Give HCO3 infusion

58. Regarding hypoglycemia:

a) It can be asymptomatic in patients treated with insulin
b) The most glucose-sensitive organ is the heart
c) Metformin is a common cause of hypoglycaemia
d) Sulphonylureas-induced hypoglycemia is quickly reversible
e) Should always be treated with intravenous dextrose
59. A lady diagnosed 4 months ago as Graves’ disease and started on carbimazole.
Now, she came for follow-up and was discovered to have early pregnancy. She
was clinically euthyroid. What is the most appropriate next step in her
management:

a) Continue on carbimazole
b) Switch her to propylthiouracil
c) Send her to surgery
d) Send her for Radioactive iodine
e) Stop anti-thyroid medications and do regular follow up

60. A 45 years old male with family history of type 2 DM presented for medical
check- up without any symptoms. Examination was unremarkable and FBG
(Fasting Blood Sugar) was 130 mg. What is the most appropriate next step?
a) Advise him to adopt healthy life style
b) Start insulin
c) Start metformin
d) Start glimepiride
e) Reassurance

61. A 35-year-old soldier presented with severe weight loss, hemoptysis and
abdominal pain. On examination he had a BMI of 12 kg/m2, malnourished,
cachectic, hyper pigmented palmar creases, RR 30/min and signs of mid-zone
consolidation in his chest. His BP was 90/60, ESR 98 and HIV serology was
negative. The next step in management is to:
a) Give prednisolone 40mg daily
b) Perform a short synacthen test
c) Avoid steroids
d) Repeat HIV test
e) Do a high dose dexamethasone suppression test

62. A 50 years old lady referred with history of progressive weight gain, she was
also concerned about multiple skin bruises. She struggled to rise from chair onto
the examination couch, BP 160/100, Weight 87, BMI 32, there was central
adiposity with multiple abdominal purple stretch marks. Which of the following
test will help establish diagnosis?
f) Short Synacthen test
g) Insulin tolerance test
h) Serum testosterone
i) 24 Hours urinary free cortisol
j) Serum T3 ,T4 & TSH
63. 55 years old diagnosed with Type 2 diabetes presented to ER with congestive
heart failure, he was treated with I/V diuretics with remarkable improvement
in his symptoms. During his stay his blood glucose was persistently high (180-
250). HbA1c 8%, estimated eGFR 40.Current medications: Gliclazide 160mg bd.
The next step would be:
a. Adding Metformin
b. Adding pioglitazone
c. No change to his current medication
d. Stop Gliclazide and start multi-dose insulin regimen
e. Add insulin to Gliclazide

64. A 30 years old patient presented with fatigue, polyuria& polydipsia for 2
weeks, his blood glucose 360 mg/dl. His father was diagnosed with Type2
diabetes 3 years ago. Which of the following is true:
a. Presence of urine ketones confirms type 1 diabetes
b. Most likely he has Type 2 diabetes
c. A low C-peptide level would lead to a diagnosis of type 1 Diabetes
d. Another blood glucose reading is needed to confirm a diagnosis of
diabetes mellitus
e. None of the above

65. 23 years old lady admitted to A&E feeling unwell, nauseated. She is conscious;
Blood pressure 80/45, Pulse 100/min regular, Temp 37 C . Systemic examination
unremarkable apart from hyperpigmentation in her hand creases. Hb 12mg/dl,
WBC 4,100, Na 128, K 5.5, urea 50 mg/dl, Blood glucose 50 mg/dl. The most
appropriate immediate management is:
a. IV normal saline, IV hydrocortisone
b. IV normal saline , oral glucose
c. IV 5% dextrose
d. IV normal saline & IV antibiotics
e. None of the above

66. Which statement is true regarding secondary hypertension?

a. In bilateral renal artery stenosis the best treatment is ACEI.
b. In phaeochromocytoma β-blockers should be started before α-blockers.
c. Spironolactone is the drug of choice in primary hyperaldosteronism.
d. Congenital adrenal hyperplasia is an important cause.
e. Rare in patients with acromegaly
67. 45 year old diabetic on glimepiride 3mg od .&metformin 500mg bid. He
presented with polydipsia & fatigability. FBS 220mg/dl .HbA1c 10. RFT &LFT
WERE Normal. The next step would be
a. increase glimepride to 3mg bid
b. increase meformin to 1gm bid
c. increase both glimepride3mg bid and metformin 1gm bid
d. start insulin
e. add pioglitazone 15mg od

68. A man has repeated episodes of flushing & wheezy chest. His CXR is normal
,however Echocardiography revealed PS & TR. HOW could you establish the
diagnosis
a. CT abomen
b. urine for VMA
c. urine for hydroxyindoleacetic acid
d. 24 hours urinary catecholamines
e. CT chest
69. 45 years old banker is recently diagnosed as type II DM. the best time to
screen him for retinopathy is
a. 5 years after the diagnosis
b. 10 years after the time of diagnosis
c. when he develop symptoms
d. At the time of the diagnosis
e. IF urinalysis revealed proteinuria

70. 50 years old lady, known case of Hashimoto thyroiditis and she has poor
compliance to L.thyroxine. She was brought to E/R comatosed, with a pulse
rate 50/min. Bp 80/50. Temp35.3. RBS 50mg/dl.What is the initial medication
to be given
a. 100 mg i.v hydrocortisone
b. I.V T3
c. oral T4
d. i.v T4
e. 0.9% Normal saline

71. A lady with graves’ disease, on carbimazole 30mg daily for one year. She
presented to her endocrinologist for follow up, she is found to be clinically &
biochemically euthyroid , but she is pregnant in the 2nd trimester. What is the
most appropriate plan of management
a. stop carbimazole and start her on propylthiouracil
b. continue on carbimazole
c. refer her for surgery
d. send her for Radioactive iodine
e. she can be on propranolol alone till delivery
72. The most common pituitary tumors are :
a. Craniopharyngioma
b. Adenomas
c. Meningioma
d. Secondaries
e. Lymphomas

73. Which of the following is NOT a recognized presentation of Pituitary tumours:

a. Divergent squint and ptosis
b. Headache
c. CSF leak
d. Homonymous hemianopia
e. High prolactin level

74. A young lady (26years) presented to the ER feeling extremely unwell, BP 90/50
pulse 100/min, nauseous, blood glucose found to be 60mg/dl. Her family
informed the doctor that she has some problems with her glands and she
stopped her medications without consulting her doctor.
Her investigations came back with a free T4 of 10 (12-22) pmol/l & random
cortisol of 70 (100-450) nmol/l. After initial resuscitation, how are you going to
manage her?
a. Start her on oral thyroxine 100 mg od
b. Start her on I/v hydrocortisone 100mg 6 hourly
c. Start her on I/v hydrocortisone and thyroxine at the same time.
d. Wait for 9:00am cortisol before giving any treatment
e. Send her for a pituitary MRI

75. A 75yr old male presents with weight gain, general fatigue, weakness,
dizziness and easy bruising. He denies any fever only a dry and irritating
persistent cough. He had no contact with patient with TB, nor on any
chronic medication. He smoked for 20 years. He sought medical advice
and was given medicine with no improvement. Examination revealed
an elderly male. BMI 45kg/m2. High BP. He had moon face, pigmented
conjunctiva, trunkal obesity, thin plethoric skin, hyperpigmented
creases. Investigations showed high random blood sugar.
Which of the following is true
a. Salivary cortisol will not give a good estimate of hypercortisolism.
b. He may have adrenal carcinoma with secondaries in the liver.
c. If ACTH is high, then he probably has ectopic secretion from probable
lung cancer.
d. Priority is to do a CT abdomen before suppression test.
e. An overnight dexamethazone suppression test (DST) is diagnostic.
76. Mahdi is a 35yr old soldier who lives in the barracks. He presented with severe
weight loss, hemoptysis and abdominal pain. On examination he had a BMI of
12kg/m2. Malnourished, cachectic. Hyperpigmented palmar creases. RR
30/min chest with Rt. mid-zone consolidation and bronchial breathing. BP low,
RBS low, High ESR, HIV negative.
The next step in management is:
a. Give prednisolone 40mg daily.
b. Disseminated TB of the adrenals is highly suggestive, so do a short
synacthen test.
c. Avoid steroids and treat for severe complicated pneumonia.
d. Repeat HIV test.
e. Do a high dose dexamethazone suppression test (DST).

77. Khadiga is 30 yrs old with generalized severe bone pain to the extent she could
not move and became bedridden. PMH was insignificant. Pregnancies and
deliveries were uneventful, but babies had neonatal convulsions at birth.
O/E stable vitals. Unremarkable systems examination. CX-Ray with multiple rib
and clavicle fracture healed with callus formation. Neck exam normal. The
following is true:
a. PTH is expensive and unnecessary
b. Ultrasound neck is not indicated in view of a normal neck examination
c. Surgery is contraindicated because of hungry bone syndrome.
d. Her babies convulsions are not related to her disease
e. This lady has long standing primary hyperparathyroidism most probably
secondary to a Parathyroid adenoma.

78. A 65year old T2DM for 16 years, on Glibenclamide, with nephropathy and
retinopathy, presents to the clinic with severe left lower limb pain and coldness
with absent pulses. HbA1c was 9%. Diagnosed as acute limb ischemia and
embolectomy done successfully. The patient was discharged home in good
condition. The best plan of management is
a. Aim at a FBS of 90-100mg/dl
b. Start Insulin and discontinue Glibenclamide even before surgery.
c. Add Metformin to his treatment.
d. Follow up with FBS and postprandial will give an excellent estimate of his
control.
e. It is advisable to see the patient in Diabetes clinic in 3 months.
79. A 19 year old man with T1DM was brought to the casuality with DKA he had
stopped taking his insulin for 2 days. Which of the following is appropriate
regarding his management.
a. Long acting basal insulins such as Glargine/Lantus is not given during the
acute phase for the management of DKA
b. Start Metformin
c. Be careful not to give too much fluids as the pt can develop heart failure
d. K and HCO3 supplements are an essential part of the treatment
e. Avoid Dextrose infusion as this can increase the blood sugar and worsen
the patient’s condition.

80. Mrs. Selma Ahmed is a 42 year old Lawyer with T2DM on premixed insulin and
Glimepiride, a short acting sulphanylurea, twice a day. As Ramadan is
approaching she comes for advice regarding fasting. She fasted 2 weeks last
year but developed hypoglycemic and stopped fasting since then. The best
advice you would give her is:
a. Fasting is contraindicated for diabetics and are not allowed to fast as they
endanger their lives.
b. If she had T1DM, fasting would help improve the blood sugar control.
c. Switch to Basal insulin (Glargine/Lantus) and reduce the dose of Glimipride to
50% at Sahoor
d. Increase sugar intake after breaking the fast so she does not develop
hypoglycemia.
e. Switch insulin to Metformin so she does not develop hypoglycemia.

81. A 70 year old female with generalized body swelling and fatigue. She has
longstanding Diabetes for 14 years, on Daonil 5mg BD. HTN for 6 years on
Losartan. She came to the clinic with increased sleepiness which her daughter
thought because of aging and immobility. Systemic review was significant for
chronic constipation, occasional chest discomfort, denies cold intolerance.
O/E: RR 12/min, HR 60/min, BP 170/80, BMI 40kg/m2, Coarse features, dry
skin, no goiter. Other system exam was normal HbA1C 12%, RFT urea 182 Cr
3.5, US kidneys: bulky size with marked corticomedullary differentiation.
ECG: LVH by voltage. Echo: Mild systolic dysfunction LVH, EF 60% no pericardial
effusion. TFT: TSH 17mU/l (0.5-5), FT3 2.0nmol/l (1-3), FT4 55nmol/l (60-145).
The following is the most appropriate thing to do:
a. Add another sulphonylurea to her medication
b. Start L-thyroxin 100 micrograms and increase the dose of Glibenclamide
c. Assure the family and ask to repeat TFT after 4 weeks
d. Metformin is a good choice as it will reduce the HbA1c effectively
e. Start L-thyroxin 25 micrograms once a day.
82. 25yr old, 26 weeks pregnant presents to the clinic with palpitations and
sweating. She had been told 1 year ago by her physician that she has
thyrotoxicosis and started treatment and when her supply of medication
finished she did not go for a refill. She was not taking any medication except
tonics and calcium. She has poor antenatal follow up and saw her obstetrician
once and he sent her to you. She has a sister who has thyroid disease.
On examination she was anxious, warm clammy hands with fine tremors, HR
100/min regular, RR 25/min, BP 140/80, eye exam, mild exophthalmos no lid
lag and lid retraction. Chest, CVS and abd normal. Inv HB 8gm LFT, RFT N, TFT:
FT3 70, FT4 182, TSH <0.02
Which of the following is correct:
a. She has thyrotoxicosis related to pregnancy and she will improve after
delivery, she does not need medication only regular follow up and
observation.
b. Propylthiouracil (PTU) is contraindicated in her case.
c. It is safe to give Carbimazole 40mg once a day aim at high normal TFT.
d. Repeat the Total T3 and T4.
e. Send her to the obstetrician to book her for a Cesarean Section.

83. 55yr old female came to your clinic and feels unwell and tired, noticed an
anterior neck swelling. Family history significant for DM and thyroid disease in
mother. Denies any cold intolerance, constipation, menopause 2 years now, no
symptoms to suggest diabetes. O/E looks healthy well no abnormality in the
skin vital signs Normal. BMI 35kg/m2 and systems normal. CBC, Hb microcytic
hypochromic anaemia, HBA1C 6%, Ca 7, FT3 1 nmol/l (1-3), FT4 80 nmol/l (60-
145), TSH 12mU/l (0.5-5)
a. This patient needs treatment as she has hyperthyroidism
b. Reassure and Follow up the patient
c. Start thyroxin because she has subclinical hypo with TSH >10
d. She has subclinical hypo with TSH >10; but no need to treat
e. Repeat the TFT
84. 22yr old male with wt loss, palpitations and people told him his eyes were
getting bigger. History is significant for anxiety b/o stress at work, indigestion and
epigastric pain, fatigue FH of diabetes, Slightly enlarged thyroid. warm clammy
extremities with tremors, Exophthalmos with lid lag and retraction O/E BP
120/80 HR 100/min irregularly irregular. RR 12/min, TSH 0.02 (0.5-5), FT4 200
nmol/l (60-145. FT3 10 nmol/l (1-3)
85. Which of the following is true about this patient?
a. He has Graves disease with ophthalmopathy, in Atrial Fibrillation so he
needs neomercazole and a beta blocker.
b. He has hypothyroidism and needs thyroxin
c. Repeat the TFT
d. refer for surgery
e. none of the above
Answer: E

d-Glycslated Hb
A=Dehydration is less severe

C= GH level

A
C = start IV NS & hydrocortisone

A= HbA1C of 7%

C = Metformin doesn’t cause hypoglycemia