Mock Endocrinology Module 6

A 50-year-old patient with Type 1 diabetes is on his second presentation to the emergency department this month following a severe hypoglycaemic episode. The patient uses multiple daily insulin injections and a Dexcom G6 continuous glucose monitoring system (CGM). He is perplexed as to why he would become severely hypoglycaemic, when his CGM readings have mostly been ‘high.’

Apart from insulin, his current medications include aspirin, simvastatin, metoprolol for previous ischaemic heart disease, and oral hydroxyurea which was recently started by his haematologist following a new diagnosis of essential thrombocythaemia.

What would be the best course of action to prevent such events from recurring?

Consider switching DEXCOM G6 to an alternative glucose monitoring approach.

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Switch to a different type of insulin to improve glycemic control.

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Reduce his insulin dosage.

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Commence him on an insulin pump therapy

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Activate hypoglycaemia alarm settings on the CGM

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Which of the following statements best describes one of the known pathophysiological mechanisms of Polycystic Ovary Syndrome (PCOS)?

Insulin resistance leads to hyperinsulinemia, which in turn triggers abnormal ovarian function in PCOS.

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PCOS is primarily caused by an excess production of androgens from the adrenal glands.

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PCOS is characterized by a deficiency in luteinizing hormone (LH) leading to anovulation.

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The main pathology in PCOS is the presence of multiple cysts in the ovaries due to blockage of the fallopian tubes.

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PCOS is due to the reduced pulsation of gonadotrophin releasing hormone from the pituitary gland.

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Which of the following is NOT part of the diagnostic criteria for Polycystic Ovary Syndrome (PCOS)?

Elevated levels of follicle-stimulating hormone (FSH)

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Hyperandrogenism

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Oligo-ovulation or anovulation

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Polycystic ovaries on ultrasound

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Exclusion of other conditions that could mimic PCOS symptoms

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A 28-year-old woman presents with complaints of excessive hair growth on her face, chest, and back. She has regular menstrual cycles and denies significant acne or alopecia.

Laboratory tests reveal:

Normal total testosterone and DHEAS
Normal 17-hydroxyprogesterone
Normal 24-hour urinary cortisol

An ultrasound of the ovaries shows no evidence of polycystic ovarian morphology.

Which of the following conditions is most likely causing her symptoms?

Idiopathic Hirsutism

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Polycystic Ovary Syndrome (PCOS)

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Idiopathic Hyperandrogenism

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Non-classic Congenital Adrenal Hyperplasia (NCCAH)

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Cushing's syndrome

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A previously fit and well 25-year-old female on the combined oral contraceptive pill (COCP), but on no other medication, presents with symptoms suggestive of hyperandrogenism, including hirsutism and acne. Despite being on the COCP, laboratory tests show elevated androgen levels.

Which of the following is the most appropriate next step in the investigation of this patient?

Discontinue the oral contraceptive pill and repeat androgen level testing in 3 months

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Initiate treatment with metformin to address insulin resistance

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Order a transvaginal ultrasound to assess for ovarian cysts

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Request for a late night salivary cortisol level.

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Request serum levels of early-morning 17-hydroxyprogesterone

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What role does anti-Müllerian hormone (AMH) play in the diagnosis of Polycystic Ovary Syndrome (PCOS)?

AMH is produced by the granulosa cells of ovarian follicles, and elevated levels are often indicative of the increased antral follicle count typical in PCOS

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AMH levels are generally lower in women with PCOS compared to those without the condition.

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AMH directly inhibits insulin resistance, which is a common feature of PCOS.

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AMH levels are not considered relevant in the diagnosis of PCOS.

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AMH can be used as a sole diagnostic marker for PCOS, eliminating the need for ultrasound and clinical assessment.

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A 58-year-old male with type 2 diabetes mellitus, hypertension, and ischaemic heart disease presents to the emergency department with severe pain, swelling, and erythema in the perineal region. He also reports fever and malaise over the past 48 hours. His medications include metoprolol, metformin, empagliflozin, lisinopril, and aspirin.

On physical examination, crepitus is noted in the affected area, and laboratory tests reveal elevated blood glucose and white blood cell counts. Imaging confirms the diagnosis of Fournier’s gangrene.

Which medication is most likely associated with the development of this patient’s condition?

Empagliflozin

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Metformin

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Lisinopril

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Aspirin

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Metoprolol

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A 73-year-old woman presents with thirst and polyuria of six months’ duration. She has suffered several episodes of lower back pain. She is on no medication. On examination, she appears well, has a dorsal kyphosis, and blood pressure of 170/95 mmHg.

Investigations:

Erythrocyte sedimentation rate: 15 mm/1st hour (0–30)
Serum urea: 11.9 mmol/L (2.5–7.5)
Serum creatinine: 175 µmol/L (60–110)
Serum albumin: 40 g/L (37–49)
Serum total calcium: 2.98 mmol/L (2.2–2.6)

What is the most likely cause of the hypercalcaemia?

Primary hyperparathyroidism

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Breast cancer with skeletal metastases

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Multiple myeloma

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Osteoporosis

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Sarcoidosis

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A 42-year-old female presents with acute back pain after lifting a chair. The pain is intense, increases on movement, and radiates bilaterally to the hypochondrial region.

Upon questioning, she denied previous fractures but admitted to a gradual loss of height (5 cm from her young adult height) and occasional self-limiting back pain.

Her past medical history includes spontaneous menopause at the age of 37. She had never taken any regular medications, calcium, or vitamin D supplements.

Examination reveals a thin woman with dorsal hyperkyphosis. Severe back pain is elicited on movement and local percussion.

Investigations: Bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry (DXA) at the hip and lumbar spine (L1–L4):

BMD T-score at lumbar spine: −3.0
BMD T-score at total hip: −2.8

What is the underlying diagnosis?

Post menopausal osteoporotic vertebral fractures

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Osteopaenia

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Osteomalacia secondary to Vitamin D or calcium deficiency

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Senile osteoporosis

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Vertebral fractures secondary to malignant infiltration

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A 40-year-old man develops sudden onset of severe frontal headache, diplopia, and nausea with vomiting. Examination reveals a cranial nerve III palsy and bitemporal hemianopia. MRI shows pituitary apoplexy.

What is the most appropriate initial step in management?

Prescribe IV dexamethasone (or IV hydrocortisone) immediately

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arrange urgent resection of pituitary adenoma

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request urgent serum prolactin

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prescribe bromocriptine 2.5mg po bd

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prescribe IV tertroxine 20mcg bd

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A 37-year-old patient with schizophrenia on olanzapine complains of muscle ache. His prolactin levels have been recorded as 870 and 980 mIU/L (normal 60–600) on two separate occasions. He is on no other medication.

Examination reveals mild gynaecomastia, no galactorrhoea or virilisation. Testicular size is normal. There are no signs of hypothyroidism.

What is the next step in management?

measure serum TSH

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commence cabergoline 0.5mg weekly

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commence bromocriptine 2.5mg daily

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arrange MRI pituitary

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measure serum testosterone

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Which of the following signs is most specific for Cushing’s syndrome?

easy bruising and poor wound healing

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weight gain

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hypertension

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abdominal circumference of 120cm

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fatigue

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Which feature is most specific for Cushing’s disease (pituitary-dependent Cushing’s syndrome)?

cortisol suppression after high dose (8mg/day) dexamethasone suppression test.

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hyperpigmentation

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elevated serum cortisol with non-suppressed ACTH

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5mm pituitary mass on MRI

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bilateral adrenal hyperplasia on CT abdoman

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A 30-year-old woman treated with cabergoline 0.5 mg weekly for amenorrhoea secondary to a 4 mm prolactinoma (microprolactinoma) consults you two weeks after recording a positive pregnancy test.

What is the most appropriate management?

cease cabergoline, monitor visual fields each trimester, and reassess need for ongoing treatment after birth

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change from cabergoline to bromocriptine 2.5mg daily during pregnancy

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arrange neurosurgical assessment

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perform MRI pituitary to determine need for dopamine agonist during pregnancy

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measure prolactin to determine need for dopamine agonist during pregnancy

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Which condition causes a predominant increase in LDL cholesterol?

Hypothyroidism

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Protease inhibitor therapy

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Type 2 diabetes

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Obesity.

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Alcohol excess.

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Which medication should be avoided when managing a thyroid storm?

Potassium perchlorate.

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Normal saline 0.9%.

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Propranolol

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Digoxin

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Dexamethasone

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Carbimazole inhibits which pathway?

Thyroid peroxidase (TPO) activity

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Sodium/iodide (Na/I) symporter

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Binding of thyroxine to thyroid binding globulin

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Thyroglobulin synthesis

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5-deiodinase activity

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A 20-year-old male patient with Type 1 diabetes on an insulin pump presents with mild DKA with pH 7.2 and a blood glucose level of 23 mmol/L.

What is the most appropriate initial intervention?

Cease the insulin pump and commence an IV insulin infusion

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Continuous insulin pump but increase the bolus doses

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Cease the insulin pump and change to a basal bolus regimen

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Continue insulin pump along with IV insulin infusion.

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Continue insulin pump and commence sc actrapid as required.

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The presence of multifocal subperiosteal bone resorption is most specific for which condition?

Hyperparathyroidism

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Rheumatoid arthritis

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Hyperthyroidism

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Gout

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Systemic lupus erythematosus

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An 85-year-old man from a rest home with type 2 diabetes presents with decreased level of consciousness. He has had watery diarrhoea with six to ten bowel movements per day for 3 days and has not taken his insulin for the past 3 days.

On examination, he is afebrile and clinically dehydrated.

Investigations:

Serum blood glucose: 25 mmol/L
Serum sodium: 150 mmol/L
Serum potassium: 5.1 mmol/L
Serum creatinine: 280 µmol/L
Serum urea: 42 mmol/L
Plasma osmolality: 375 mOsm/kg

You decide to administer IV insulin.

Which set of electrolyte changes is most likely to occur after intravenous insulin is administered?

An increase in serum sodium and a decrease in serum potassium level

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A decrease in serum sodium level and an increase in serum potassium level

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An increase in serum sodium and potassium levels

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No change in serum sodium level and an increase in serum potassium level

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A decrease in serum sodium and potassium levels

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Which medication is NOT approved for the prevention (as opposed to treatment) of postmenopausal osteoporosis?

Teriparatide

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Alendronate

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Risedronate

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Zoledronic acid

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Bazedoxifene

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The most potent biphosphonate is?

Zoledronic acid

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Alendronate

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Risedronate

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Etidronate

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Ibandronate

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What is the BMI threshold for recommending metabolic surgery in caucasian patients with Type 2 diabetes regardless of their glycemic control?

BMI ≥40 kg/m2

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BMI ≥50 kg/m2

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BMI ≥35 kg/m2

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BMI ≥30 kg/m2

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BMI ≥45 kg/m2

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Romosozumab is a monoclonal antibody used in the treatment of osteoporosis in postmenopausal women at high risk of fracture. It works by binding against which protein?

Sclerostin

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RANKL

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OPG

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Cathepsin K

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GSK-3

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A 52-year-old Māori man attends his general practice for a routine cardiovascular risk assessment. He has no symptoms of hyperglycaemia. His HbA1c returns at 50 mmol/mol (previously 44 mmol/mol eighteen months ago).

What is the most appropriate next step?

Arrange a confirmatory HbA1c as soon as practical before making the diagnosis

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Diagnose diabetes without further confirmatory testing and initiate metformin

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Reassure the patient that this represents prediabetes and repeat in 12 months

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Perform a 75 g oral glucose tolerance test to confirm the diagnosis

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Repeat the HbA1c only if fasting blood glucose is elevated

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Clinical inertia is likely the largest barrier to effective diabetes management. The following interventions are all recommended to reduce clinical inertia EXCEPT:

Confirm Type 2 diabetes only once the patient is symptomatic

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Start lifestyle management and metformin together at diagnosis to delay progression of T2D

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Consider starting a second-line agent with metformin at diagnosis if the patient’s HbA1c > 64 mmol/mol

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If the initial HbA1c is above 90 mmol/mol at diagnosis, then start weight-based basal insulin and add prandial insulin once basal insulin doses reach 0.5 units/kg/day.

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Proactive screening in at-risk populations

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A 42-year-old Māori male presents for a routine check-up. He is a current smoker with a history of hypertension, hyperlipidaemia, and a BMI of 30 kg/m². His HbA1c taken last week was 45 mmol/mol. He is currently asymptomatic.

What is the best course of action for this man right now?

Advise on lifestyle changes and start Metformin.

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Repeat his HbA1c in 3 months and commence Metformin once HbA1c reaches 50mmol/mol

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Commence basal insulin

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Advise on lifestyle changes alone

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Repeat his HbA1c in one year

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In patients with Type 2 diabetes and a BMI over 30 kg/m², what is the recommended target total body weight loss to help achieve diabetes remission?

5-10% of total body weight

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10-15% of total body weight

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1-5% of total body weight

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15-20% of total body weight

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A 46-year-old woman with a body mass index of 34 kg/m² is diagnosed with type 2 diabetes (HbA1c 54 mmol/mol; confirmed). She has had the diagnosis for less than 12 months and is highly motivated. She asks about the possibility of achieving remission.

Which single factor is the strongest predictor of successful, durable remission of type 2 diabetes?

Shorter duration of diabetes at the time of intervention

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The absolute HbA1c value at diagnosis

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The presence of coexisting hypertension

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Baseline low-density lipoprotein cholesterol level

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Whether metformin was commenced at diagnosis

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When managing patients with Type 2 diabetes, a more aggressive HbA1c target of <48 mmol/mol may be appropriate for the following patient groups EXCEPT:

Young patients with short diabetes duration

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Pregnant patients

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Patients at risk of or with early microvascular complications (to prevent progression)

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Patients with cognitive impairment

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Patients who can safely achieve target without significant hypoglycaemia

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The combination of SGLT2 inhibitor and GLP-1 receptor agonist (dual therapy) in Type 2 diabetes is likely to produce the following effects EXCEPT:

Significant reduction in glycemic levels

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Significant reduction in body weight

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Significant reduction in blood pressure

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Significant reduction in hypoglycaemia risk

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Significant reduction in BMI

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At what eGFR threshold should metformin be discontinued in patients with chronic kidney disease?

eGFR <15 ml/min

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eGFR 30-45 ml/min

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eGFR 15-30 ml/min

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eGFR >65 ml/min

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eGFR 45-65 ml/min

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Which of the following diabetic medications causes weight loss without inducing hypoglycaemia?

Empagliflozin

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Sulphonylurea

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Insulin

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Vildagliptin

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Pioglitazone

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A 47-year-old Tongan male was recently diagnosed with Type 2 diabetes with an HbA1c of 50 mmol/mol. He was advised on lifestyle changes and commenced on oral metformin. However, three months later, his HbA1c has risen to 60 mmol/mol. His renal function is normal and he is of normal weight. There is no history of heart failure or established cardiovascular disease.

His GP is considering adding a second agent. Assuming SGLT2 inhibitors and GLP-1 receptor agonists are not funded or affordable, which of the following medications would be the most appropriate for this man?

Vildagliptin

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Pioglitazone

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Insulin

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Glipizide

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Glibenclamide

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Retatrutide helps achieve weight loss via the following mechanisms EXCEPT:

stimulates insulin release.

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reduces glucagon release.

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appetite suppressor.

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reduces glucagon production.

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adipose tissue modulation.

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A 44-year-old woman is newly diagnosed with type 2 diabetes after a confirmed HbA1c of 49 mmol/mol. Her HbA1c was documented at 44 mmol/mol 14 months earlier. She is asymptomatic and has normal vision.

Regarding diabetic retinal screening, which is the most appropriate approach?

Defer the first retinal screening for 3 years and create a recall

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Refer for retinal screening urgently within 2 weeks

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Do not refer, as retinal screening is not required in type 2 diabetes

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Refer for retinal screening immediately as per standard practice

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Refer only if she develops visual symptoms

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A 71-year-old man with a 15-year history of type 2 diabetes has moderate frailty, established ischaemic heart disease, and stage 3b chronic kidney disease. He is currently on metformin, gliclazide and basal insulin. His HbA1c is 51 mmol/mol. He has had two recent episodes of symptomatic hypoglycaemia.

Which is the most appropriate management adjustment?

Relax the glycaemic target and de-intensify therapy by reducing the sulfonylurea and/or insulin

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Intensify therapy to achieve an HbA1c < 48 mmol/mol

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Maintain the current regimen unchanged as the target is met

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Add a GLP-1 receptor agonist to improve glycaemic control

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Increase basal insulin to suppress hepatic gluconeogenesis

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Mock Endocrinology Module 6

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