問題1
A 67-year-old woman presented to her general practitioner with a swelling in her neck. It had been present for 4-5 years and had not changed in size during that time. She was completely asymptomatic and remained well.
On examination, there was a nodular goitre and no lymphadenopathy.
Investigations:
serum thyroid-stimulating hormone1.1 mU/L (0.4-5.0)
A subsequent ultrasound scan demonstrated seven nodules bilaterally (ranging in size from 5 mm to 15 mm), which had no suspicious features.
What is the most appropriate next step in management according to British Thyroid Association 2014 Guidelines for the Management of Thyroid Cancer?
A 67-year-old woman presented to her general practitioner with a swelling in her neck. It had been present for 4-5 years and had not changed in size during that time. She was completely asymptomatic and remained well.
On examination, there was a nodular goitre and no lymphadenopathy.
Investigations:
serum thyroid-stimulating hormone1.1 mU/L (0.4-5.0)
A subsequent ultrasound scan demonstrated seven nodules bilaterally (ranging in size from 5 mm to 15 mm), which had no suspicious features.
What is the most appropriate next step in management according to British Thyroid Association 2014 Guidelines for the Management of Thyroid Cancer?
正確答案: C
問題2
A 36-year-old woman was referred to the endocrine clinic with abnormal thyroid function
tests. She gave a 3-year history of increased sweating and anxiety following an assault and, initially, her symptoms had been attributed to post-traumatic stress disorder.
Investigations:
serum thyroid-stimulating hormone (TSH)3.1 mU/L (0.4-5.0)
serum free T429.8 pmol/L (10.0-22.0)
serum free T33.5 pmol/L (3.0-7.0)
What is the most likely interpretation of her thyroid function test results?
A 36-year-old woman was referred to the endocrine clinic with abnormal thyroid function
tests. She gave a 3-year history of increased sweating and anxiety following an assault and, initially, her symptoms had been attributed to post-traumatic stress disorder.
Investigations:
serum thyroid-stimulating hormone (TSH)3.1 mU/L (0.4-5.0)
serum free T429.8 pmol/L (10.0-22.0)
serum free T33.5 pmol/L (3.0-7.0)
What is the most likely interpretation of her thyroid function test results?
正確答案: D
問題3
A 32-year-old woman, with a 22-year history of type 1 diabetes mellitus, was seen in a pre-pregnancy diabetes clinic. She was a primigravida.
On examination, she had early background retinopathy, her blood pressure was 128/68 mmHg, and her body mass index was 29.7 kg/m2 (18-25).
Investigations:
haemoglobin A1c56 mmol/mol (20-42)
urinary albumin:creatinine ratio1.2 mg/mmol (<3.5)
Over the years her haemoglobin A1c concentration had varied between 58 and 69 mmol/mol. She had impaired awareness of hypoglycaemia and experienced approximately two severe hypoglycaemic events per year. She was worried about the risk of severe congenital malformations in her baby.
To what extent will the average risk of severe congenital malformation be increased in infants born to this mother with pregestational diabetes?
A 32-year-old woman, with a 22-year history of type 1 diabetes mellitus, was seen in a pre-pregnancy diabetes clinic. She was a primigravida.
On examination, she had early background retinopathy, her blood pressure was 128/68 mmHg, and her body mass index was 29.7 kg/m2 (18-25).
Investigations:
haemoglobin A1c56 mmol/mol (20-42)
urinary albumin:creatinine ratio1.2 mg/mmol (<3.5)
Over the years her haemoglobin A1c concentration had varied between 58 and 69 mmol/mol. She had impaired awareness of hypoglycaemia and experienced approximately two severe hypoglycaemic events per year. She was worried about the risk of severe congenital malformations in her baby.
To what extent will the average risk of severe congenital malformation be increased in infants born to this mother with pregestational diabetes?
正確答案: D
問題4
A 26-year-old woman with previously well-controlled primary hypothyroidism had been an in patient for treatment of an eating disorder for the previous 6 weeks. She had a history of anaemia resulting from multiple vitamin deficiency and gastric erosions. She had been taking levothyroxine 125 micrograms daily for the previous 5 years; since admission her medication had also included ferrous sulfate, calcium and vitamin D, and sucralfate. Her daily medicines were taken under supervision at 09.00 h. Although she was eating better and had gained 4 kg in weight, she was now complaining of tiredness and feeling "worse than ever".
On examination, she was thin, slightly pale and had no palpable goitre. Recent blood tests had confirmed that her anaemia had resolved.
Investigations:
serum corrected calcium2.28 mmo/L (2.20-2.60)
serum thryoid-stimulating hormone12.0 mU/L (0.4-5.0)
serum free T48.0 pmol/L (10.0-22.0)
serum T30.90 nmol/L (1.07-3.18)
What is the most appropriate next step in management?
A 26-year-old woman with previously well-controlled primary hypothyroidism had been an in patient for treatment of an eating disorder for the previous 6 weeks. She had a history of anaemia resulting from multiple vitamin deficiency and gastric erosions. She had been taking levothyroxine 125 micrograms daily for the previous 5 years; since admission her medication had also included ferrous sulfate, calcium and vitamin D, and sucralfate. Her daily medicines were taken under supervision at 09.00 h. Although she was eating better and had gained 4 kg in weight, she was now complaining of tiredness and feeling "worse than ever".
On examination, she was thin, slightly pale and had no palpable goitre. Recent blood tests had confirmed that her anaemia had resolved.
Investigations:
serum corrected calcium2.28 mmo/L (2.20-2.60)
serum thryoid-stimulating hormone12.0 mU/L (0.4-5.0)
serum free T48.0 pmol/L (10.0-22.0)
serum T30.90 nmol/L (1.07-3.18)
What is the most appropriate next step in management?
正確答案: E
問題5
A 36-year-old man of South Asian origin presented acutely with a widespread pruritic rash involving the extensor surfaces of the limbs.
On examination, he was moderately obese with a body mass index of 33 kg/m2 (18-25), and the rash was erythematous, with multiple small papules with yellow centres.
Investigations:
fasting plasma glucose11.0 mmol/L (3.0-6.0)
haemoglobin A1c109 mmol/mol (20-42)
serum cholesterol8.0 mmol/L (<5.2)
serum HDL cholesterol0.80 mmol/L (>1.55)
fasting serum triglycerides31.00 mmol/L (0.45-1.69)
What is the most likely diagnosis?
A 36-year-old man of South Asian origin presented acutely with a widespread pruritic rash involving the extensor surfaces of the limbs.
On examination, he was moderately obese with a body mass index of 33 kg/m2 (18-25), and the rash was erythematous, with multiple small papules with yellow centres.
Investigations:
fasting plasma glucose11.0 mmol/L (3.0-6.0)
haemoglobin A1c109 mmol/mol (20-42)
serum cholesterol8.0 mmol/L (<5.2)
serum HDL cholesterol0.80 mmol/L (>1.55)
fasting serum triglycerides31.00 mmol/L (0.45-1.69)
What is the most likely diagnosis?
正確答案: E
問題6
A 27-year-old woman with type 1 diabetes mellitus was invited to attend a structured education (e.g. DAFNE) coursE.
Which quality of life domain is most affected when a person is found to have type 1 diabetes mellitus?
A 27-year-old woman with type 1 diabetes mellitus was invited to attend a structured education (e.g. DAFNE) coursE.
Which quality of life domain is most affected when a person is found to have type 1 diabetes mellitus?
正確答案: A
問題7
A 47-year-old man presented with a 2-month history of polyuria and polydipsia. He awoke six times most nights to pass copious volumes of urine despite not drinking any fluid for 4 hours before going to bed.
Investigations:
MR scan of pituitary fossasee image
A water deprivation test confirmed the diagnosis of cranial diabetes insipidus.
What is the most likely underlying diagnosis?
A 47-year-old man presented with a 2-month history of polyuria and polydipsia. He awoke six times most nights to pass copious volumes of urine despite not drinking any fluid for 4 hours before going to bed.
Investigations:
MR scan of pituitary fossasee image
A water deprivation test confirmed the diagnosis of cranial diabetes insipidus.
What is the most likely underlying diagnosis?
正確答案: D
問題8
A 23-year-old man presented with a history of discomfort with his gender for as long as he could remember. He believed he was transsexual.
What element of further history would most strongly support his self-diagnosis?
A 23-year-old man presented with a history of discomfort with his gender for as long as he could remember. He believed he was transsexual.
What element of further history would most strongly support his self-diagnosis?
正確答案: C
問題9
A 17-year-old boy was concerned about his height. He had been treated for Crohn's disease since the age of 13 with a combination of topical and systemic corticosteroids and azathioprine. He was currently taking mercaptopurinE.
On examination, his height was on the 25th centile.
Investigations:
X-ray of right kneesee image
What is the most appropriate next step in management?
A 17-year-old boy was concerned about his height. He had been treated for Crohn's disease since the age of 13 with a combination of topical and systemic corticosteroids and azathioprine. He was currently taking mercaptopurinE.
On examination, his height was on the 25th centile.
Investigations:
X-ray of right kneesee image
What is the most appropriate next step in management?
正確答案: E
問題10
A 56-year-old man with a 5-year history of type 2 diabetes mellitus was worried about developing a foot ulcer.
Which clinical feature, if present, best predicts the development of a foot ulcer in a patient with diabetes?
A 56-year-old man with a 5-year history of type 2 diabetes mellitus was worried about developing a foot ulcer.
Which clinical feature, if present, best predicts the development of a foot ulcer in a patient with diabetes?
正確答案: D
問題11
A 63-year-old woman with diet-controlled type 2 diabetes mellitus was admitted with biventricular cardiac failure. She had a history of myocardial infarction 3 years previously. She was taking aspirin 75 mg daily, simvastatin 20 mg daily, furosemide 40 mg daily and ramipril 10 mg daily. She responded well to increased diuretic therapy.
Urinalysis showed glucose 1+.
Investigations:
haemoglobin112 g/L (115-165)
serum sodium135 mmol/L (137-144)
serum potassium4.7 mmol/L (3.5-4.9)
serum creatinine162 umol/L (60-110)
estimated glomerular filtration rate28 mL/min/1.73 m2 (>60)
serum troponin T<0.01 ug/L (<0.01)
haemoglobin A1c66 mmol/mol (20-42)
What is the most appropriate treatment for her diabetes after discharge?
A 63-year-old woman with diet-controlled type 2 diabetes mellitus was admitted with biventricular cardiac failure. She had a history of myocardial infarction 3 years previously. She was taking aspirin 75 mg daily, simvastatin 20 mg daily, furosemide 40 mg daily and ramipril 10 mg daily. She responded well to increased diuretic therapy.
Urinalysis showed glucose 1+.
Investigations:
haemoglobin112 g/L (115-165)
serum sodium135 mmol/L (137-144)
serum potassium4.7 mmol/L (3.5-4.9)
serum creatinine162 umol/L (60-110)
estimated glomerular filtration rate28 mL/min/1.73 m2 (>60)
serum troponin T<0.01 ug/L (<0.01)
haemoglobin A1c66 mmol/mol (20-42)
What is the most appropriate treatment for her diabetes after discharge?
正確答案: C
問題12
A 72-year-old man with a 12-year history of type 2 diabetes mellitus was found to have carcinoma of the bladder. He was taking metformin; however, this was stopped because of his deteriorating renal function.
On examination, his weight was 95 kg and his body mass index was 32 kg/m2 (18-25).
Investigations:
serum sodium143 mmol/L (137-144)
serum potassium4.4 mmol/L (3.5-4.9)
serum creatinine175 umol/L (60-110)
estimated glomerular filtration rate (MDRD)27 mL/min/1.73 m2 (>60)
haemoglobin A1c64 mmol/mol (20-42)
What is the most appropriate addition to his medication?
A 72-year-old man with a 12-year history of type 2 diabetes mellitus was found to have carcinoma of the bladder. He was taking metformin; however, this was stopped because of his deteriorating renal function.
On examination, his weight was 95 kg and his body mass index was 32 kg/m2 (18-25).
Investigations:
serum sodium143 mmol/L (137-144)
serum potassium4.4 mmol/L (3.5-4.9)
serum creatinine175 umol/L (60-110)
estimated glomerular filtration rate (MDRD)27 mL/min/1.73 m2 (>60)
haemoglobin A1c64 mmol/mol (20-42)
What is the most appropriate addition to his medication?
正確答案: B
問題13
A 19-year-old man was seen in the diabetes clinic. He had lost 2 kg in weight since the diagnosis of diabetes mellitus 18 months previously. At presentation, his body mass index was 33 kg/m2 (18-25), his random plasma glucose was 18.0 mmol/L and his haemoglobin A1c was 56 mmol/mol (20-42). He was taking gliclazide, and metformin had been added later. His father and grandfather had developed diabetes mellitus during their twenties.
Investigations:
haemoglobin A1c56 mmol/mol (20-42)
serum C-peptide301 pmol/L (180-360)
anti-glutamic acid decarboxylase (GAD)
antibodiesnegative
What is the most likely diagnosis?
A 19-year-old man was seen in the diabetes clinic. He had lost 2 kg in weight since the diagnosis of diabetes mellitus 18 months previously. At presentation, his body mass index was 33 kg/m2 (18-25), his random plasma glucose was 18.0 mmol/L and his haemoglobin A1c was 56 mmol/mol (20-42). He was taking gliclazide, and metformin had been added later. His father and grandfather had developed diabetes mellitus during their twenties.
Investigations:
haemoglobin A1c56 mmol/mol (20-42)
serum C-peptide301 pmol/L (180-360)
anti-glutamic acid decarboxylase (GAD)
antibodiesnegative
What is the most likely diagnosis?
正確答案: A