MCQs for Specialty Certificate Examination (SCE)

in Endocrinology and Diabetes

MCQs (46 -60)

Collected by : Dr . AHMED ELKONDI

MRCGP int
Specialty Certificate in Endocrinology and Diabetes
46 -A 32-year old women complains of amenorrhea since delivery of a baby 15 months previously, despite the
fact that she did not breast feed her baby. The delivery was complicated by excessive hemorrhage that required
transfusion of 2.5 liters of blood. She has also been fatigued and has gained an additional 10 pounds since the
baby was born.
A. Hashimoto's thyroiditis
B. Isolated gonadotropin deficiency
C. Primary amenorrhea
D. Prolactinoma
E. Sheehan's syndrome

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46-Correct answer: E
Sheehan's syndrome is hypopituitarism due to ischemic damage to the pituitary resulting from excessive hemorrhage during parturition. The
pituitary is enlarged during pregnancy; it is more metabolically active, and more susceptible to hypoxemia. Furthermore, the blood vessels in
the pituitary may be more susceptible to vasospasm because of the high estrogen.
The symptoms depend on how much of the pituitary is damaged and what cell types are destroyed.
The patient described above exhibited persistent amenorrhea after delivery of her infant. This is due to destruction of pituitary gonadotrophs
and diminished secretion of gonadotropins (LH). There also appears to have been significant destruction of lactotrophs since TRH injection
failed to induce an increase in prolactin. lead to failure to lactate
This case is also characterized by secondary hypothyroidism. The low TSH and failure to respond to TRH injection is confirmatory.
Isolated gonadotropin deficiency (choice B) produces amenorrhea and is associated with low serum LH and estradiol. Hypogonadotropic
hypogonadism can occur in female athletes that over-train, in anorexia nervosa, in obesity, or with other emotional or physical stresses.
However, other pituitary hormones are unaffected (by definition isolated gonadotropin deficiency only involves a decrease in gonadotropins).
Primary amenorrhea (choice C), by definition, means failure of menstrual cycles to ever begin. Since this woman has delivered a baby,
primary amenorrhea is highly unlikely.
A prolactinoma (choice D) is a functional pituitary tumor that secretes excessive prolactin. This can cause amenorrhea by suppressing the
GnRH-pituitary-gonad axis
47-ADH-secreting small cell carcinoma of the lung cause :
A. Polyuria, increased thirst, low urine osmolality
B. Obesity, abnormal glucose tolerance curve, hypertension, osteoporosis
C. Low plasma osmolality, dilutional hyponatremia, high urine osmolality
D. Hypertension, increased levels of metanephrines in urine
E. Bitemporal hemianopsia, amenorrhea, galactorrhea, infertility

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47-Correct answer: C
Low plasma osmolality, dilutional hyponatremia, high urine osmolality
Syndrome of inappropriate ADH secretion:
-ADH excess à excessive amounts of free water resorbed
-most common causes include secretion of ectopic ADH by malignant neoplasms, non-neoplastic
diseases of the lung, and local injury to they hypothalamus
Clinical manifestations:
-hyponatremia, cerebral edema, neurologic dysfunction
-total body water is increased, blood volume remains normal & peripheral edema doesn’t develop
48-Bacterial meningitis
A. Polyuria, increased thirst, low urine osmolality
B. Obesity, abnormal glucose tolerance curve, hypertension, osteoporosis
C. Low plasma osmolality, dilutional hyponatremia, high urine osmolality
D. Hypertension, increased levels of metanephrines in urine
E. Bitemporal hemianopsia, amenorrhea, galactorrhea, infertility

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48-Correct answer: A
Polyuria, increased thirst, low urine osmolality
A complications of bacterial meningitis include the syndrome of inappropriate antidiuretic
hormone secretion, seizures, and increased intracranial pressure.
49- All of the following clinical and laboratory data would be consistent with a diagnosis of
SIADH (Syndrome of Inappropriate ADH secretion), EXCEPT:
A-Hyponatremia (Dilutional)
B-Clinical presentation may include seizures and coma
C-Low serum osmolality (Hemodilution)
D-Excessively hypotonic (Dilute) urine

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49-Correct answer: D
Excessively hypotonic (Dilute) urine
SIADH is a condition characterized by serum hypo-osmolality and hyponatremia,
resulting from secretion of antidiuretic hormone (ADH). The patient may be at risk when
serum Na falls below 135 meq/l; mild to moderate risk when serum Na is 120 meq/l to 110
meq/l; and severe risk when Na is less than 110 meq/l.
Features of SIADH include low serum sodium and low serum osmolality, increased urine
as well as osmolality and increased urinary sodium concentration (> 20 mmol/L).
Clinically, most patients with SIADH are euvolemic
50- Mr. Jones, a 40 year old white man, goes to his local plastic surgeon complaining of
getting old before his time. His facial features have coarsened, and his shoe size has increased
from an 11C to a 14 EEEE over 10 years. His Yankee baseball cap no longer fits. What is
worse, he has the recent onset of diabetes, blinding headaches and visual problems. The most
likely finding:
A. Macroadenoma of pituitary with enlarged sella turcica
B. Microdenoma of pituitary with bilateral adrenal hyperplasia
C. Microadenoma of pituitary with gynecomastia
D. Pituitary adenocarcinoma with metastases to the lung
E. Sarcoidosis involving the pituitary

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50- Correct answer: A

Macroadenoma of pituitary with enlarged sella turcica
51- ACTH-secreting pituitary adenoma
A. Polyuria, increased thirst, low urine osmolality
B. Obesity, abnormal glucose tolerance curve, hypertension, osteoporosis
C. Low plasma osmolality, dilutional hyponatremia, high urine osmolality
D. Hypertension, increased levels of metanephrines in urine
E. Bitemporal hemianopsia, amenorrhea, galactorrhea, infertility

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51-Correct answer: B
Obesity, abnormal glucose tolerance curve, hypertension, osteoporosis
52-Which of the following condition(s) is not associated with hyperprolactinemia?
A. Chronic renal failure
B. Exogenous estrogen administration
C. Diabetes mellitus
D. Cirrhosis

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52-Correct answer: C
Elevated serum prolactin levels do not always indicate the presence of a pituitary tumor. Important
alternative causes are chronic renal failure, hypothyroidism, various drugs including phenothiazines,
tricyclic antidepressants, exogenous estrogen, opiates, reserpine, verapamil and others. In addition,
hepatic disease, pregnancy and a variety of pituitary and hypothalamic lesions cause
hyperprolactinemia. If the prolactin level is over 150 ng/ml, a pituitary tumor is almost invariably the
cause, but often microadenomas produce prolactin levels of less than 100 ng/ml. The size of pituitary
tumors has been shown to relate to the degree of prolactin elevation, which may reach into the
thousands of nanograms per milliliter. There are no reliable provocative tests to differentiate
prolactinomas from other causes of hyperprolactinemias, so the diagnosis relies on ruling out other
causes and imaging of the adenoma.
53-A 30-year-old woman presents with amenorrhea, headache and bitemporal hemianopsia.
Appropriate diagnostic tests include:
A. Cerebral angiography
B. Serum prolactin levels
C. Magnetic resonance imaging of the brain
D. Abdominal and pelvic CT scan

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53-Correct answer: B
Patients with pituitary lesions present symptoms and signs related to a mass effect on the pituitary and its
surrounding structures, to hypersecretion of the hormones by the lesion itself, or to a combination of both.
As mass lesions in the pituitary enlarge, they encounter the various contents of the cavernous sinuses,
including the third, fourth, sixth and first two divisions of the fifth cranial nerves, as well as the internal
carotid artery. The growth of a tumor in the relatively unrestricted upward direction is much more
common and often results in compression of the optic chiasm with the resultant loss of vision, typically a
bitemporal hemianopsia. Prolactin-secreting pituitary adenomas often present with endocrine symptoms
including amenorrhea and galactorrhea in women. In men, the loss of libido, infertility and visual loss are
typical. Magnetic resonance imaging (MRI) has evolved as the first choice for diagnostic imaging and is
often the only tool needed to reach a therapeutic decision with regard to pituitary adenomas MRI
demonstrates intrasellar tumors as small as 5 mm. CT scanning has a place in pituitary imaging if MRI
scanning is unavailable.
54- 54-Which of the following statement is true with respect to growth hormone secreting pituitary adenomas?
A. Fewer than 50% of patients will have growth hormone levels over 10 ng/mL
B. Oral glucose administration suppresses growth hormone levels in patients with acromegaly
C. Over 80% of growth hormone-secreting microadenomas can be cured with transphenoidal resection
D. Preoperative treatment of macroadenomas with a somatostatin analogue may not improve postoperative remission rates

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54- Correct answer: C

The endocrine diagnosis of acromegaly rests largely on serum growth hormone (GH) levels, because 90%
of patients will have levels over 10ng/mL.
glucose suppression test is the most useful diagnostic procedure. In normal patients, 1 to 2 hours after the
oral administration of 100 g of glucose, the growth hormone level falls well below 5 ng/mL. This
suppression is not seen with GH-secreting adenomas, and often a paradoxical rise in GH is observed.
The goals of treatment are to lower the circulating growth hormone or somatomedin C levels to within a
normal range and to reduce the size of the mass lesion causing compression-related symptoms. When a
microadenoma is removed transsphenoidally, endocrine remission may be expected in 80% to 88% of
cases. When a macroadenoma is resected, postoperative remission is reported in 30% to 68% of cases. The
rate of remission is inversely related to preoperative GH levels and tumor size. Preoperative treatment of
macroadenomas with a somatostatin analogue may improve postoperative remission rates
.
55 - 27 year old female with massive postpartum hemorrhage and failure to lactate
A. Sheehan’s syndrome
B. Addison’s disease
C. Sipple’s syndrome
D. Nelson’s syndrome
E. Waterhouse-Friderichsen’s syndrome

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55 - Correct answer A.
Sheehan's syndrome (mostly in patients who have experienced severe post-partum hemorrhage
with hypotensive shock.
• Post-partum ischemic necrosis of anterior pituitary
• Failure of lactation, amenorrhea, atrophy of breasts, loss of pubic/axillary hair,
superinvolution of uterus, hypothyroidism, adrenal cortical insufficiency
•IV corticosteroids, fluids, and endocrinologic confirmation of diagnosis
56- Which of the following statements regarding the pituitary gland are true?
A. ADH is a product of the adenohypophysis
B. The preferred surgical approach to the pituitary gland is via the sphenoid sinus
C. Growth hormone, ACTH, LH, FSH and serotonin are products of the adenohypophysis
D. The adenohypophysis is regulated by neurotransmitters released by the supraoptic hypophyseal tract

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56- Correct answer B .

The anterior pituitary gland is the adenohypophysis which constitutes 80% of the gland.
The posterior pituitary, the neurohypophysis, constitutes the remainder and should be considered virtually an
extension of the hypothalamus of the brain.
The adenohypophysis is regulated by a portal venous system between the median eminence of the
hypothalamus and the adenohypophysis itself. This system involves a transport of (1) thyrotropin-releasing
hormone (TRH), to stimulate the secretion of the thyroid-stimulating hormone (TSH); (2) corticotropin-
releasing hormone, to stimulate adrenocorticotropic hormone (ACTH); (3) growth hormone-releasing
hormone, to stimulate secretion of growth hormone (GH); (4) gonadotropin-releasing hormone, to stimulate
luteinizing hormone (LH) and follicle-stimulating hormone (FSH); and (5) prolactin-inhibitory factor
(dopamine), to inhibit prolactin. The neurohypophysis is regulated by means of direct transport of hormones
through nerve fibers from the supraoptic and paraventricular nuclei in the hypothalamus.
Products of the neurohypophysis are antidiuretic hormone (ADH; vasopressin) and oxytocin. The pituitary
gland is not known to release serotonin.
57- A 53-year-old woman presented with symptoms of increased thirst, weight loss and an increased frequency
of passing urine. She had
a background medical history of bronchial asthma for which she occasionally used a salbutamol inhaler. On
examination, her BMI was 29 kg/m2. Her general physical and systemic examination was unremarkable except
for central adiposity. Her fasting and random glucose readings were 6.5 and 9.2 mmol/L, respectively.
Which one of the following biochemical cut-offs are diagnostic of diabetes, based on World Health Organization
(WHO) criteria?
A.1-hour plasma glucose ≥11.1 on oral glucose tolerance test
B. Fasting glucose ≥6 mmol/L, with osmotic symptoms
C. Fasting glucose ≥7 mmol/L in an asymptomatic patient
D. Random glucose ≥8.5 mmol/L in an asymptomatic patient
E. Random glucose ≥11.1 mmol/L, with osmotic symptoms

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57- Correct answer E.

According to the World Health Organization (WHO) criteria for the diagnosis of diabetes:
• A patient is diagnosed to have diabetes if he/she has osmotic symptoms, with biochemical evidence of random
glucose ≥11.1 mmol/L; or fasting glucose ≥7 mmol/L; or 2-hour plasma glucose ≥11.1 on oral glucose tolerance test.
•An asymptomatic patient is diagnosed to have diabetes if he/she has biochemical evidence of fasting glucose ≥7
mmol/L or random glucose ≥11.1, with a second confirmatory plasma venous glucose measurement to be repeated on
another day, with the glucose reading in the diabetic range (fasting, random, or 2-hour post-glucose tolerance test).
In 2011, the WHO criteria added HbA1c as a diagnostic tool, with a cut-off of 6.5% (48 mmol/mol) needed to
diagnose diabetes
58- HbA1c is a commonly used tool that is employed for the diagnosis of diabetes. Although it is highly specific for the
diagnosis of diabetes, it is not particularly sensitive, with relatively more probability of obtaining a false negative test result.
Which one of the following is an appropriate indication for the use of HbA1c for the diagnosis of diabetes?
A Children
B. Diabetes in adulthood
C. Patients on steroids
D. Patients with acute pancreatic damage
E. Pregnancy

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58- Correct answer : B

HbA1c is not appropriate for use in the diagnosis of diabetes in the following situations:
• Patients on steroids or antipsychotics that can increase blood glucose readings
• Patients with acute pancreatic damage
• Pregnancy
• Patients suspected of having Type 1 DM
• Children and young adults
• Haemoglobinopathies, which can influence HbA1c results
• Patients with short duration of osmotic symptoms
59- A 38-year-old man of Afro-Caribbean origin presented to the medical assessment unit with a 2-day history of feeling nauseous and
generally unwell. He had a strong family history of diabetes. On examination, he had a BMI of 29 kg/m2, with features of dehydration, a pulse
rate of 104 beats/minute, and blood pressure of 90 mmHg systolic. His systemic examination was unremarkable.
Investigations:
Blood sugar mmol/L 28
pH 7.37 )7.45–7.35(
HCO3 mmol/L 23 )27–22(
Na mmol/L 134 )145–135(
K mmol/L 4.5 )4.5–3.5(
Amylase IU/L 22 )125<(
Urine +Sugar +++, ketones 4

He was initially managed on a basis of insulin and intravenous fluids. He made a good clinical recovery and was discharged home with pre-mix
insulin (70/30) injections bd. His subsequent blood tests show a negative anti-glutamic acid decarboxylase (GAD) antibody status.
Which one of the following is the most appropriate management approach for him when he is reviewed in a follow-up clinic visit in 4 weeks’
time?
A. Consideration for insulin pump therapy
B. Continue insulin therapy life long
C. Switch to metformin
D. Switch to pioglitazone
E. Switch to sulfonylureas

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59- Correct answer C.
Ketosis-prone diabetes is more common in black and Hispanic ethnic subgroups. The patients are
generally obese and may present with features of diabetic ketoacidosis. The autoimmune antibody status
(anti-GAD antibodies) is generally negative. The management is initially on the lines of diabetic
ketoacidosis (fluids/insulin/potassium replacement). Most of these patients can be managed on oral
hypoglycaemic agents, with the discontinuation of insulin therapy within a few weeks to months.
60- A 32-year-old woman presented to her GP with osmotic symptoms (polydipsia and polyuria). She had a
background history of sensorineural deafness, with a strong family history of diabetes (mother, maternal
grandmother, and a few maternal cousins having Type 1 or Type 2).
On examination, she had a BMI of 22 kg/m2, with no clinical features of Cushing’s syndrome or hirsutism.
Investigations:
Blood sugar 15.5 mmol/L
pH 7.37 (7.35–7.45)
Venous HCO3 23 mmol/L (22–27)
Sodium 138 mmol/L (135–145)
Potassium 4.2 mmol/L (3.5–4.5)
Which one of the following is the most appropriate initial therapy, based on her clinical profile?
A. Incretins
B. Insulin
C. Metformin
D. Pioglitazone
E. Sulfonylurea

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60 - Correct answer E.
Mitochondrial diabetes is suspected in female patients with a strong familial clustering of diabetes, with
predominantly maternal transmission of disease and the presence of sensorineural deafness. The degree
and severity of insulinopenia is variable, with patients developing either Type 1 or Type 2 DM. The
underlying defect in the majority of patients is the mitochondrial gene mutation (A3243G). The initial
treatment of individuals with Type 2 DM presentation due to an underlying mitochondrial mutation can
be with sulfonylureas. Metformin is contraindicated due to the risk of development of lactic acidosis.
Hearing defects usually precede the development of diabetes in these patients.
Thyroid dysfunction screening:
Population
-Asymptomatic nonpregnant adults.
-Newborns.
Recommendations
-Insufficient evidence to recommend for or against routine screening for thyroid disease in asymptomatic adults without risk factors
- consider screening patients older than 60, those with risk factors, and women planning pregnancy.
-Screen all newborns for congenital hypothyroidism.
-Screen adults with risk factors for hypothyroidism.
-Screen adults with laboratory or radiologic abnormalities that could be caused by thyroid disease.
-Use serum TSH to screen for thyroid disease.
-Do not test for thyroid disease in hospitalized patients unless thyroid disease is strongly suspected.
Comments
1. Individuals with symptoms and signs potentially attributable to thyroid dysfunction require TSH testing.
2. Less than 1% of adults have subclinical hypothyroidism; outcomes data to support treatment are lacking.
Subclinical hyperthyroidism detected during routine screening may be treated in select patients at
high risk of cardiovascular or skeletal complications.
3. Higher risk individuals are those with autoimmune disorders (eg, type 1 diabetes), pernicious anemia, goiter, previous radioactive
iodine therapy and/or head-and-neck irradiation or surgery, pituitary or hypothalamic disorders, first-degree relative with a thyroid
disorder, use of medications that may impair thyroid function, and those
with psychiatric disorders.
4. Thyroid function should be measured in patients with the following:
 substantial hyperlipidemia
 hyponatremia
 high-serum muscle enzymes
 macrocytic anemia
 pericardia! or pleural effusions.
5. Consider TSH screening in infertile women attempting pregnancy.
ADRENAL INCIDENTALOMAS - MANAGEMENT
Population
-Adults.
Recommendations
-Evaluate clinically, biochemically, and radiographically for evidence of
 Hypercortisolism
 aldosteronism,
 presence of pheochromocytoma
 malignant tumor.
-Reevaluate patients who will be managed expectantly at 3-6 mo and then annually for 1-2 y.
Comments
1. A 1-mg overnight dexamethasone suppression test can be used to screen for hypercortisolism.
2. Measure plasma-fractionated metanephrines and normetanephrines
to screen for pheochromocytoma.
3. Measure plasma renin activity and aldosterone concentration to assess for primary or secondary aldosteronism.
CUSHING'S SYNDROME (CS) MANAGEMENT
Population
-Pediatric and adult patients with Cushing's syndrome.
Recommendations
-Treatment goals for Cushing's syndrome
• Normalize cortisol levels to eliminate the signs and symptoms of CS.
• Monitor and treat cortisol-dependent comorbidities.
-Recommend vaccinations against
 influenza,
 herpes zoster,
 pneumococcus.
-Recommend perioperative thromboprophylaxis for venous thromboembolism.
-Recommend surgical resection of primary adrenal or ectopic focus underlying CS.
-Assess postoperative serum cortisol levels.