SEND - Endocrinology and Diabetes (Specialty Certificate Examination) v6.0 (SEND)

A 37-year-old man, who had previously undergone female-to-male gender reassignment surgery, attended the endocrine clinic for annual review. He had no complaints and was happy with the results of his treatment. His medication consisted of testosterone undecanoate 1 g intramuscularly every 3 months.
What variable is it most important to monitor?

A 46-year-old South Asian man presented with a 2-month history of dry mouth and polyuria. He had hypertension treated with bendroflumethiazide. There was no family history of diabetes mellitus, but his father had died suddenly during lower limb angioplasty at the age of 51.
On examination, the patients pulse was 76 beats per minute and regular, and his blood pressure was 164/86 mmHg. The rest of the physical examination was normal. Urinalysis was normal.
Investigations:
serum sodium143 mmol/L (137144)
serum potassium3.0 mmol/L (3.54.9)
serum creatinine123 mol/L (60110)
fasting plasma glucose6.9 mmol/L (3.06.0)
What is the most appropriate next step in management?

A 32-year-old man presented with medullary thyroid cancer, treated by total thyroidectomy.
He had a past history of primary hyperparathyroidism, treated by selective parathyroidectomy. Postoperatively, plasma calcitonin was undetectable and serum calcium was in the normal range.
Investigations:
RET genotypeheterozygote codon 634 C>T mutation
What is the most appropriate approach to annual screening for phaeochromocytoma?

A 36-year-old woman was seen in the clinic with a recurrence of hyperthyroidism after a 2- year remission. She had been treated with carbimazole for 18 months following her original presentation. She was moderately symptomatic and was keen to be treated in the same way again. She was planning a pregnancy.
Investigations:
serum prolactin240 mU/L (<360)
serum thyroid-stimulating hormone<0.1 mU/L (0.45.0)
serum free T428.0 pmol/L (10.022.0)
anti-thyroid-stimulating hormone receptor
antibodies44 U/L (<7)
What is the most appropriate next step in management?

A 17-year-old boy with a 7-year history of type 1 diabetes mellitus was transferred to the adolescent diabetes clinic. He had a history of poor clinic attendance. He admitted to having lost weight recently. His eyes had been photographed by a community ophthalmologist 1 week previously. A photograph of the right fundus is shown (see image).

A 23-year-old woman was found to have type 1 diabetes mellitus following a short history of polyuria, polydipsia and unintentional weight loss. She started taking insulin aspart before meals and insulin detemir daily.
What is the most appropriate time from diagnosis to start screening for microalbuminuria?

A 67-year-old woman presented to her general practitioner with a swelling in her neck. It had been present for 45 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 (0.45.0)
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 61-year-old woman was found incidentally to have a raised serum calcium concentration.
She was otherwise well. Her father had undergone a neck operation many years previously.
Investigations:
serum corrected calcium2.78 mmol/L (2.202.60)
plasma parathyroid hormone10.8 pmol/L (0.95.4)
Her general practitioner thought she had primary hyperparathyroidism.
Which further finding is most likely to cast doubt upon this diagnosis?

A 55-year-old man with mild polyuria and tiredness was seen on a renal ward. He had had a living-related kidney transplant 6 months previously. He had good graft function while being treated with prednisolone 5 mg daily, mycophenolate mofetil 1 g twice daily and tacrolimus 3 mg twice daily. He was also taking atenolol 50 mg daily and simvastatin 40 mg daily.
Investigations:
haemoglobin A1c75 mmol/mol (2042)
random plasma glucose18.0 mmol/L
Which drug is most likely to be responsible for his diabetes of new onset?

A 58-year-old man was referred to the endocrine clinic after a CT scan of abdomen had shown a 4.5-cm left adrenal mass, with a Hounsfield unit measurement of 11 (consistent with high lipid content). He had a 10-year history of type 2 diabetes mellitus and was taking metformin. He was also taking atenolol for hypertension.
On examination at the clinic, his blood pressure was 162/94 mmHg. He was centrally obese with a body mass index of 27 kg/m2 (1825).
Investigations:
serum potassium3.9 mmol/L (3.54.9)
plasma renin activity (after 30 min upright)1.0 pmol/mL/h (3.04.3) plasma aldosterone (after 4 h upright)680 pmol/L (330830) overnight dexamethasone suppression test (after 1 mg dexamethasone): serum cortisol164 nmol/L (<50)
24-h urinary free cortisol132 nmol (55250)
24-h urinary catecholamines
(adrenaline and noradrenaline)normal
As the lesion was >4 cm in diameter, laparoscopic adrenalectomy was recommended.
What is the most appropriate advice to give to the surgical team about perioperative management?

A 58-year-old woman was referred with an incidental finding of mild hypercalcaemia. She had no relevant symptoms or significant medical history. She was taking no medication.
Investigations:
serum creatinine101 mol/L (60110)
serum corrected calcium2.71 mmol/L (2.202.60)
serum alkaline phosphatase78 U/L (45105)
plasma parathyroid hormone6.8 pmol/L (0.95.4)
serum 25-OH-cholecalciferol76 nmol/L (4590)
What is the most appropriate next investigation?

A 42-year-old woman, with type 1 diabetes mellitus of 22 years duration, attended for annual review. She was using biphasic insulin twice daily and taking aspirin 75 mg, simvastatin 40 mg and ramipril 10 mg daily.
On examination, her blood pressure was 164/87 mmHg.
Investigations:
serum potassium5.9 mmol/L (3.54.9)
serum creatinine197 mol/L (60110)
estimated glomerular filtration rate (MDRD)26 mL/min/1.73 m2 (>60) haemoglobin A1c72 mmol/mol (2042) urinary albumin:creatinine ratio27.0 mg/mmol (<3.5) urine culturenegative
What is the most important next step in management?

A 36-year-old man of African origin attended the clinic 2 weeks after discharge from hospital following his first admission with diabetic ketoacidosis. He had made a rapid recovery and had been discharged taking subcutaneous insulin twice daily.
At clinic, he reported home blood glucose measurements of 46mmol/L, occasional symptomatichypoglycaemia and a total daily insulin dose of 12 units. He asked if his glucose-lowering treatment should change.
Which test is most likely to predict prolonged insulin independence?

A 69-year-old man with type 2 diabetes mellitus presented with a 3-day history of an ulcer on his right second toe.
On examination, the toe was red, swollen and enlarged, and looked like a sausage digit.
The ulcer appeared superficial.
Investigations:
X-ray of right second toeno sign of osteomyelitis
Cultures from the debrided wound bed were taken and the results were awaited.
What is the most appropriate type of antibiotic regimen to start empirically before the culture results are available?

A 73-year-old man with type 2 diabetes mellitus was reviewed because of borderline hypertension. He was taking metformin 1 g twice daily, gliclazide 160 mg twice daily, aspirin 75 mg daily and simvastatin 20 mg at night. He had a history of diabetic retinopathy.
On examination, his body mass index was 34 kg/m2 (1825); his blood pressure was
146/86 mmHg. When he returned 2 months later, his blood pressure was 142/88 mmHg.
Investigations:
serum creatinine102 mol/L (60110)
haemoglobin A1c66 mmol/mol (2042)
urinary albumin:creatinine ratio
(untimed specimen)7.4 mg/mmol (<2.5)
According to NICE guidelines (CG66, May 2008), what is the target for blood pressure reduction?