A 33-year-old obese woman complains of tiredness. She has recently given birth to a healthy baby boy and is enjoying being a mother. However, she is becoming more reliant on her partner for support as she always feels exhausted and often becomes depressed. The patient has a poor appetite and often does not finish her meals, despite this she has gained 5 kg in the last 2 weeks. The most likely diagnosis is:

A. Postpartum depression B. Eating disorder C. Hyperthyroidism D. Hypothyroidism E. Occult malignancy

3. Weight gain

A 28-year-old woman has noticed a change in her appearance; most notably her clothes do not fit properly and are especially tight around the waist. Her face appears flushed and more rounded than usual, despite exercising regularly and eating healthily her weight has steadily increased over the last 3 weeks. On visiting her GP, he notices her blood pressure has increased since her last visit and she has bruises on her arm. She is especially worried about a brain tumour. The most appropriate investigation would be:

A. Low-dose dexamethasone test B. High-dose dexamethasone test C. Urinary catecholamines D. Computed tomography (CT) scan E. Urinary free cortisol measurement

4. Sleep apnoea

A 49-year-old man presents with a history of difficulty sleeping. He reports feeling increasingly tired and general weakness which he attributes to his poor sleep pattern. Additionally, the patient has noticed he has gained weight and sweats very easily. On examination, the patient has coarse facial features. The most likely diagnosis is:

A. Hyperthyroidism B. Cushing’s disease C. Acromegaly D. Hypothyroidism E. Diabetes

5. Visual disturbance

A 42-year-old woman presents with visual disturbances. She reports having double vision which was intermittent initially but has now become much more frequent. In addition, she becomes breathless very easily and experiences palpitations. On examination, raised, painless lesions are observed on the front of her shins and finger clubbing. The most likely diagnosis is:

A. De Quervain’s thyroiditis B. Thyroid storm C. Phaeochromocytoma D. Graves’ disease E. Plummer’s disease

6. Goitre

A 16-year-old girl presents to her GP complaining of a swelling in her neck which she has noticed in the last 2 weeks. She has felt more irritable although this is often transient. On examination, a diffuse swelling is palpated with no bruit on auscultation. The most likely diagnosis is:

A. Hyperthyroidism B. Simple goitre C. Riedel’s thyroiditis D. Thyroid carcinoma E. Thyroid cyst

7. Dizziness

A 22-year-old woman complains of dizziness and feeling light-headed. She works in an office and most frequently experiences this when standing up to visit the toilet. She has never fainted. The patient has lost 5 kg, but attributes this to eating more healthily. She has noticed a recent scar on the back of her hand which has started to turn very dark. The most appropriate investigation is:

A. Synacthen test B. Low-dose dexamethasone test C. Cortisol measurement D. Urinary free cortisol measurement E. Abdominal ultrasound (US) scan

8. Polyuria

A 29-year-old man presents with a 4-week history of polyuria and extreme thirst. The patient denies difficulty voiding, hesitancy or haematuria, although the urine is very dilute. The patient does not believe he has lost any weight and maintains a good diet. No findings are found on urine dipstick. The most appropriate investigation is:

A. Serum osmolality B. Fasting plasma glucose C. Urinary electrolytes D. Magnetic resonance imaging (MRI) scan of the head E. Water deprivation test

9. Confusion (1)

A 69-year-old man presents with confusion. His carers state that over the last month he has become increasingly lethargic, irritable and confused. Despite maintaining a good appetite, he has lost 10 kg in the last month. Blood results are as follows:

The most likely diagnosis is:

A. Hypothyroidism B. Dilutional hyponatraemia C. Addison’s disease D. Acute tubulointerstitial nephritis E. Syndrome of inappropriate anti-diuretic hormone (SIADH)

10. Stridor

A 54-year-old woman presents to her GP complaining of a change in her breathing sound. She first noticed numbness, particularly in her fingers and toes, three months ago but attributed this to the cold weather. Her partner now reports hearing a high pitched, harsh sound while she is sleeping. Her BMI is 27. While measuring blood pressure, you notice the patient’s wrist flexing. The most likely diagnosis is:

A. Obstructive sleep apnoea B. Hypocalcaemia C. DiGeorge syndrome D. Guillain-Barré syndrome E. Raynaud’s syndrome

11. Depression

A 39-year-old man presents with a three-month history of depression. The patient recently lost a family member and around the same period began to feel unwell with constipation and a depressed mood. He has started taking analgesia for a sharp pain in his right lower back that often radiates towards his front. The most appropriate investigation is:

A. Serum parathyroid hormone B. Serum thyroid stimulating hormone C. Colonoscopy D. Fasting serum calcium E. MRI scan

12. High blood pressure

A 47-year-old woman presents to clinic after being referred from her GP for consistently elevated blood pressure. Her last reading was 147/93. The female does not report any symptoms but recently lost her job and attributes the elevated reading to stress. Her blood tests are as follows:

The most appropriate investigation is:

A. CT scan B. 24-hour ambulatory blood pressure C. Abdominal ultrasound scan D. Aldosterone-renin ratio E. Glucose tolerance test

13. Panic attack

A 65-year-old woman complains of panic attacks. She has recently retired as a school teacher, but 2-3 times a week she suffers extreme anxiety, becomes short of breath and sweats excessively. Elevated catecholamines are detected in the urine. The most appropriate medical treatment is:

A. Phenoxybenzamine alone B. Prolopanolol alone C. Phenoxybenzamine followed by propanolol D. Sodium nitroprusside E. Propanolol followed by phenoxybenzamine

14. Weight loss

A 47-year-old woman complains of weight loss. She has a family history of type 1 and type 2 diabetes but has never been diagnosed herself despite the finding of islet cell antibodies. In the last few months, however, she has noticed progressively increasing polyuria and poydipsia and 5 kg of weight loss. Her fasting plasma glucose is 8 mmol/L and urine dipstick shows the presence of ketones. The most likely diagnosis is:

A. Type 1 diabetes B. Non-ketotic hyperosmolar state C. Type 2 diabetes D. Occult malignancy E. Latent autoimmune diabetes of adults (LADA)

15. Diabetes management (1)

A 50-year-old Asian man is referred to the diabetes clinic after presenting with polyuria and polydipsia. He has a BMI of 30, a blood pressure measurement of 137/88 and a fasting plasma glucose of 7.7 mmol/L. The most appropriate first-line treatment is:

A. Dietary advice and exercise B. Sulphonylurea C. Exenatide D. Thiazolidinediones E. Metformin

16. Neuropathy

A 55-year-old diabetic woman presents with altered sensations in her hands and feet. She finds it difficult to turn pages of books and discriminating between different coins. When walking, the floor feels different and she likens the sensation to walking on cotton wool. The most likely diagnosis is:

A. Autonomic neuropathy B. Diabetic amyotrophy C. Acute painful neuropathy D. Symmetrical sensory neuropathy E. Diabetic mononeuropathy

17. Abdominal lump

A 29-year-old woman is referred to a diabetic clinic for poor diabetes management. She was diagnosed with type 1 diabetes at the age of 12 and prescribed actrapid insulin injections. Recently, the patient has been suffering fluctuations in her plasma glucose levels and her previously well-controlled glycated haemoglobin has risen to 8.1 per cent. The patient admits she has recently been avoiding using her injections. On examination, the patient has a raised, smooth lump that is firm on palpation at the lower abdomen. The most likely diagnosis is:

A. Worsening of diabetes B. Lipohypertrophy C. Injection scarring D. Lipoma E. Injection abscess

18. Headache

A 15-year-old girl complains of headaches which started 6 weeks ago. The headaches initially occurred 1-2 times a week but now occur up to five times a week, they are not associated with any neurological problems, visual disturbances, nausea or vomiting. The girl also reports a white discharge from both of her nipples. She has not started menstruating. The most appropriate investigation is:

A. Lateral skull x-ray B. CT scan C. MRI scan D. Thyroid function tests E. Serum prolactin measurement

19. Striae

A 7-year-old girl presents with red striae which her mother noticed around her abdomen. The girl also has plethoric cheeks and, on her back, several faint, irregular brown macules are observed. The mother is particularly concerned about the early breast development that seems apparent on her daughter. Serum phosphate is decreased. The most likely diagnosis is:

A. Paget’s disease of the bone B. McCune-Albright syndrome C. Cushing’s disease D. Hypopituitarism E. Neurofibromatosis

20. Delayed puberty

An 18-year-old man presents to clinic worried about his scant pubic hair development. Examination reveals undescended testes and plasma testosterone, luteinizing hormone and follicle stimulating hormone were found to be low. A karytotype test was 46, XY. The patient was otherwise well, but during neurological examination struggled during the olfactory test. The most likely diagnosis is:

A. Hypogonadotropic hypogonadism B. Klinefelter’s disease C. Androgen insensitivity syndrome D. 5-alpha reductase deficiency E. Kallman’s syndrome

21. Room temperature intolerance

A 47-year-old woman is referred to the endocrine clinic complaining of a twomonth history of tiredness. Despite wearing several items of clothing, the patient appears intolerant to the room temperature. She has noticed an increase in weight, particularly around her waist. The most appropriate investigation is:

A. Radioiodine scan B. Thyroid stimulating hormone (TSH) C. Total tetraiodothyronine level (T4) D. Tri-iodothyronine level (T3) E. Ultrasound scan of the neck

22. Painful neck

A 58-year-old woman presents with an acutely painful neck, the patient has a fever, blood pressure is 135/85 mmHg and heart rate 102 bpm. The patient explains the pain started 2 weeks ago and has gradually become worse. She also notes palpitations particularly and believes she has lost weight. The symptoms subside and the patient presents again complaining of intolerance to the cold temperatures. The most likely diagnosis is:

A. Thyroid papillary carcinoma B. Plummer’s disease C. De Quervain’s thyroiditis D. Hyperthyroidism E. Thyroid follicular carcinoma

23. Abdominal pain

A 6-year-old girl presents to accident and emergency with severe abdominal pain, nausea and vomiting. On examination, the patient is tachypnoeic, capillary refill is 3 seconds and she has a dry tongue. While listening to the patient’s lungs, you detect a sweet odour from her breath. The most likely diagnosis is:

A. Diabetic ketoacidosis B. Non-ketotic hyperosmolar state C. Gastroenteritis D. Pancreatitis E. Adrenal crisis

24. Bilateral adrenalectomy complication

A 45-year-old Asian man is diagnosed with Cushing’s disease in India. He undergoes a bilateral adrenalectomy and recovers well from the operation. On his return to the UK one year later, he complains of a constant dull headache, peripheral visual disturbances and increasing pigmentation of the skin creases of both hands. The most likely diagnosis is:

A. Ectopic ACTH secreting tumour B. Prolactinoma C. Nelson syndrome D. Addison’s disease E. Side effects from iatrogenic steroid intake

25. Loss of consciousness

A 29-year-old woman is found unconscious by her partner and rushed to accident and emergency. She is a type 1 diabetic and has maintained excellent glucose control using insulin injections. Blood biochemistry results demonstrate a moderately raised level of insulin, no detectable C-peptide and very low blood glucose. Her partner mentions she is a lawyer and has been working particularly hard in the last week, eating quick meals and occasionally missing meals. The most likely diagnosis is:

A. Hyperosmolar coma B. Diabetic ketoacidosis C. Insulin overdose D. Hypoglycaemic coma E. Autonomic neuropathy

26. Diabetes management (2)

A 49-year-old man has recently been diagnosed with type 2 diabetes and is being carefully monitored. He has been advised to maintain a healthier diet and lifestyle, he attends a follow-up clinic and claims to have been following the diet stringently since his last appointment three months ago. The most appropriate investigation is:

A. Random plasma glucose B. Fasting plasma glucose C. Urine dipstick D. Glycated haemoglobin E. Weight measurement

27. Diabetes treatment

A 41-year-old man has been recently diagnosed with type 2 diabetes and has been following a plan of lifestyle measures to improve his diet and increase his level of exercise. On returning to clinic, his BMI is 23, fasting plasma glucose 9.0 mmol/L, blood pressure 133/84 mmHg and HbA1c of 7.1 per cent. The most appropriate treatment option is:

A. Metformin B. Sulphonylurea C. Insulin D. Exenatide E. Further diet and exercise

28. Parasthesia

A 33-year-old man complains of a tingling sensation in his hands for several months which occasionally awakens him during sleep. The patient has noticed he has gained weight and no longer wears his wedding ring as it has become too tight. You notice the patient is sweating while speaking to you and has quite a large jaw, furrowed tongue and large hands. His blood pressure reading is 142/91 mmHg. The most appropriate investigation would be:

A. MRI scan of the pituitary B. Glucose tolerance test C. Growth hormone levels D. Thyroid function tests E. Serum prolactin levels

29. Prognathism

A 19-year-old woman presents with concerns about changes to her facial appearance, in particular her nose and jaw seem quite large, she is also quite sweaty and despite using antiperspirants is finding it difficult to control and is afraid of embarrassment at university. A glucose tolerance test is performed and found to be raised. The most appropriate management would be:

A. Trans-sphenoidal surgery B. Octreotide C. Bromocriptine D. Pituitary radiotherapy E. Pegvisomant

30. Impaired fasting glucose

A 29-year-old man presents to his GP complaining of being constantly thirsty, tired and visiting the toilet more often than usual during the last 4 days. He has noticed his clothes have become more baggy and he now needs to tighten his belt. His parents both have diabetes requiring insulin therapy. A fasting plasma glucose result is most likely to be:

A. 9.0 mmol/L B. 6.0 mmol/L C. 16.3 mmol/L D. 5.0 mmol/L E. 3.0 mmol/L

31. Ketonuria

A 22-year-old woman is found unconscious in her room by her boyfriend and brought into accident and emergency. A urine dipstick is positive for glucose and ketones and blood analysis shows the following results:

The most likely anion gap is:

A. 180 B. 118 C. 139.2 D. 46.1 E. 28

32. Quadrantanopia

A 37-year-old man presents with symptoms of an acute headache, vomiting, malaise and visual disturbance. A neurological examination reveals a bitemporal superior quadrantanopia. A CT scan shows a hyperdense area within the pituitary gland. The most likely diagnosis is:

A. Kallman syndrome B. Septo-optic dysplasia C. Sheehan’s syndrome D. Empty sella syndrome E. Pituitary apoplexy

33. Facial plethora

A 38-year-old woman presents to clinic complaining of changes in her appearance and weight gain. She has recently been through a divorce and attributed her weight gain to this. However, despite going to the gym her clothes are still tight, especially around her waist, her face seems puffy and flushed. The most likely diagnosis is:

A. Hyperthyroidism B. Cushing’s disease C. Acromegaly D. Hypothyroidism E. Diabetes

34. Collapse

A 60-year-old diabetic man recovering from sepsis after collapsing at home was treated with appropriate antibiotics after blood culture and aggressive fluid management with 0.9 per cent saline for 2 days for hypotension. Although blood pressure returned to normal, the patient had the following abnormal biochemical blood results:

The most likely diagnosis is:

A. Diabetic ketoacidosis B. Lactic acidosis C. Conn’s syndrome D. Renal tubular acidosis type 1 E. Hyperchloremic acidosis

35. Confusion

A 57-year-old woman, who has recently returned from a holiday in America, presents with dull grey-brown patches in her mouth and the palms of her hand which she has noticed in the last week. She has also noticed she gets very dizzy when rising from a seated position and is continually afraid of fainting. The most likely diagnosis is:

A. Addison’s disease B. SIADH C. Conn’s syndrome D. Waterhouse-Friderichsen syndrome E. 17-hydroxylase deficiency