MRCPUK SEND Exam Questions
SEND - Endocrinology and Diabetes (Specialty Certificate Examination) (Page 3 )

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 (3.5–4.9) serum creatinine197 µmol/L (60–110)
-estimated glomerular filtration rate (MDRD)26 mL/min/1.73 m2 (>60) haemoglobin A1c72 mmol/mol (20–42)
-urinary albumin:creatinine ratio27.0 mg/mmol (<3.5) urine culturenegative

What is the most important next step in management?

A 55-year-old man with type 2 diabetes mellitus presented with foot swelling and discomfort. He had a peripheral sensory neuropathy attributed to diabetes mellitus. A midfoot Charcot’s arthropathy was suspected, and a plain X-ray was arranged (see image).


Which is the talonavicular joint?

A 54-year-old woman attended clinic for routine follow-up. She had Cushing’s syndrome secondary to ectopic adrenocorticotropic hormone syndrome with no primary source identified.

She had declined bilateral adrenalectomy. Routine medication included metyrapone 500 mg three times daily, ketoconazole 200 mg once daily and hydrocortisone 10 mg in the morning and 5 mg in the evening.

Metyrapone inhibits the action of which enzyme in steroidogenesis?

A 76-year-old man with a 17-year history of type 2 diabetes mellitus attended for his annual review. Comparison of his retinal screening report with the previous year’s report showed that his visual acuity was unchanged at 6/9 in both eyes. The previous year’s right eye retinal image had been reported as ‘pre- proliferative retinopathy’, whereas this year’s was reported as ‘pre-proliferative retinopathy with maculopathy’. What is the most appropriate next step?

A 32-year-old woman presented to the outpatient clinic with a 1-year history of amenorrhoea that began after stopping her oral contraceptive pill. She had previously had two successful pregnancies and was otherwise well. Examination was normal and no visual field defect was present on testing to confrontation.

Investigations:
-serum sodium138 mmol/L (137–144) serum potassium3.8 mmol/L (3.5–4.9)
-plasma follicle-stimulating hormone2.0 U/L (2.5–10.0) plasma luteinising hormone2.0 U/L (2.5–10.0)
-serum prolactin1050 mU/L (<360) MR scan of pituitarysee image



What is the most appropriate treatment?