The SAQs printed in the CME section can only be answered online to achieve external CPD credits.
Any comments should be sent in via email only: clinicalmedicine@rcplondon.ac.uk
Format
SAQs follow a best of five format in line with the MRCP(UK) Part 1 exam. Candidates are asked to choose the best answer from five possible answers.
The answering process
Go to www.rcplondon.ac.uk/SAQ
Log on using your usual RCP username and password
Select the relevant CME question paper
Answer all 10 questions by selecting the best answer from the options provided
Once you have answered all the questions, click on Submit
Registering your external CPD credits
Carrying out this activity allows you to claim two external CPD credits. These will be automatically transferred to your CPD diary, where you can review the activity and claim your points.
A 37-year-old woman was brought to the emergency department having been found confused at home by her husband. While in the emergency department she had a series of generalised seizures and afterwards was post-ictal. She had a history of depression and mild asthma. Her medication comprised oral fluoxetine, which had been started recently and salbutamol inhalers. There is no history of chronic alcohol use.
On examination she was drowsy with a Glasgow coma score of 13/15. She was apyrexial. Her heart rate was 100 beats-per-minute and regular, her blood pressure was 122/76 mmHg and she was clinical euvolaemic. Her respiratory rate was 22 breaths-per-minute and her oxygen saturation was 95% on 35% oxygen. Blood tests from 1 month ago had shown normal serum electrolytes.
Investigations:
View this table:What is the most appropriate treatment?
0.9% sodium chloride infusion
3% sodium chloride infusion
demeclocycline
fluid restriction to 800 ml/day
tolvaptan
A 77-year-old man was referred to the medical admissions unit with a 3-day history of confusion. He had lost 7 kg in weight over the previous 4 months. He had a history of type 2 diabetes and epilepsy. His medication comprised metformin, gliclazide and carbamazepine.
On examination, his heart rate was 68 beats-per-minute and his blood pressure was 134/86 mmHg sitting with no orthostatic drop. His jugular venous pressure was normal and he had no oedema. His abbreviated mental state score was 5/10, but there were no focal neurological signs.
Investigations:
View this table:What is the most likely cause for the hyponatremia?
Addison’s disease
hepatic cirrhosis
hypothyroidism
syndrome of inappropriate ADH (SIADH)
uncontrolled diabetes
A 35-year-old woman was referred to the outpatient clinic following abnormal thyroid results. She was entirely asymptomatic and the blood tests were organised as part of a routine screen. Some of her relatives have been told that their thyroid results are abnormal but that they do not need any specific form of treatment.
Examination was normal.
Investigations:
View this table:What is the most likely diagnosis?
antibody interfering with TSH assay
euthyroid sick syndrome
primary hypothyroidism
thyroid hormone resistance
TSH-secreting pituitary adenoma
A 22-year-old woman was reviewed in the thyroid clinic. She had presented with a nodule in her neck two years previously. Fine needle aspiration had shown medullary thyroid cancer and she had gone on to have a total thyroidectomy. Histology had shown an isolated medullary thyroid cancer with no spread outside of the thyroid gland. There was no family history of tumours associated with multiple endocrine neoplasia syndromes, but genetic testing showed a mutation in the RET gene of the patient consistent with multiple endocrine neoplasia type 2A.
On examination she had a thyroidectomy scar. Her blood pressure was 123/73 mmHg. There were no other abnormal signs.
Investigations
View this table:She had a two-year old daughter who had been screened and found to carry the same RET gene mutation.
What is the best advice regarding the management of her daughter?
annual screening with plasma calcitonin levels
computed tomography (CT) scan of the neck every 5 years
prophylactic thyroidectomy at an age based on the specific mutation
screening blood tests after the age of 16 in adult endocrine clinic
screening is unhelpful, so wait for symptoms to appear
A 56-year-old man was referred to the outpatient clinic with a 3-month history of general muscle aches, constipation and 6 kg weight loss. He had hypertension and type 2 diabetes diagnosed 5 years previously. His medication comprised bendroflumethiazide, ramipril and metformin. He was also taking an over-the-counter multivitamin and vitamin D. He had a 30 pack-year smoking history.
On examination, his body mass index was 26 kg/m2 and his blood pressure was 122/65 mmHg. His chest was hyperexpanded, but there were no other abnormal signs.
Investigations:
View this table:What is the most likely diagnosis?
primary hyperparathyroidism
familial hypocalciuric hypercalcaemia
side effect of bendroflumethiazide
small cell lung cancer
vitamin D excess
A 50-year-old man was referred to the outpatient clinic with a 3-month history of intermittent episodes of confusion and unsteadiness. Episodes typically occurred several hours after eating and his symptoms improved within a few minutes of consuming simple carbohydrate. Since the onset of symptoms, he had gained 10 kg in weight. On one occasion an ambulance had been called and a capillary blood glucose value of 1.2 mmol/l had been recorded.
His father had a history of parathyroidectomy for hyperparathyroidism.
Examination was normal.
Investigations performed during an admission for a 72-h fast and at the time of symptoms:
View this table:An abnormality in which gene is responsible for this condition?
calcium sensing receptor gene
MEN1
RET
succinate dehydrogenase (SDH) B
von-Hippel Lindau gene
A 45-year-old man was admitted after he had fallen from his bicycle injuring his head. He had been unconscious for 10 minutes afterwards.
On examination, he had some facial lacerations, but no other injury. His Glasgow Coma Score was 15/15 and there were no neurological signs in his limbs. He was noted to have a bitemporal hemianopia.
Investigations:
View this table:What is the most likely diagnosis?
lymphocytic hypophysitis
macroprolactinoma
microprolactinoma
non-functioning pituitary macroadenoma
thyroid-stimulating hormone secreting tumour
A 35-year-old woman was referred to the outpatient department with a 5-day history of severe anterior neck pain, fatigue and lethargy. She had no past medical history and was on no medication.
Examination of her neck showed a smooth, tender, diffuse goitre but no lymphadenopathy. There was no pharyngitis and she was apyrexial. Her heart rate was 100 beats-per-minute and blood pressure 111/65 mm Hg.
Investigations:
View this table:What is the most likely diagnosis?
auto-immune hyperthyroidism
post-partum thyroiditis
multinodular goitre
Grave’s disease
subacute viral (de Quervain’s) thyroiditis
A 56-year-old man was referred to the outpatient department following the finding of mild hypercalcaemia. He had presented to his general practitioner with a 2-month history of tiredness and fatigue. His mood was generally good, he had no bowel disturbance and no history of nephrolithiasis. He was on no prescribed medication, but took a daily over-the-counter multivitamin preparation. There was no family history of calcium disorder.
Examination was normal.
Investigations:
View this table:What is the most likely diagnosis?
familial hypocalciuric hypercalcaemia
malignancy
primary hyperparathyroidism
sarcoidosis
vitamin D excess
A 38-year-old woman was referred to the outpatient clinic for investigation of migrainous headaches. A magnetic resonance imaging (MRI) scan of her head had been performed which showed no intracranial lesion, but the report mentioned an incidental 0.9 mm low-density lesion in the pituitary fossa.
Examination was unremarkable with no clinical evidence of pituitary hypersection or hyposecretion.
Investigations:
View this table:What is the most appropriate management approach?
hydrocortisone replacement
oral cabergoline
pituitary radiotherapy
consideration of follow-up imaging in 6–12 months
trans-sphenoidal surgery
- © 2013 Royal College of Physicians
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