Endocrinology RACP MCQs Flashcards by Jaspreet Unknown

RACP 2022a
8. 69 year old man presenting with intermittent headaches and fatigue. Low testosterone and high prolactin. Lots of blood results. Prolactin 77000,
GH/LH/FSH/cortisol normal. MRI with lesion size (20mmx16mmx-18mm) that is in close proximity to optic chiasm. His formal visual field testing is normal.
What is the best management?
a. Somatostatin analogue
b. Dopamine agonist
c. Transsphenoidal surgery

ANS: C

https://www.ncbi.nlm.nih.gov/books/NBK278983/

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RACP 2022a
14. An 18 year old male presents with bilateral painful gynecomastia. Resting tachycardia on exam. He has high total testosterone, normal free testosterone (4.5) and elevated SHBG (192). FSH and LH (low normal, not suppressed), prolactin normal, TSH < 0.01. His BMI is 18. What is the most likely cause
a. Exogenous testosterone use
b. Pituitary adenoma
c. Grave’s Disease

ANS: C

SHBG increased with hypogonadism, anorexia, T1DM, hyperthyroidisim, aromatase inhibitors

Gynaecomastia can be caused by hyperthyroidism

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RACP 2022a
19. A 24 year old man has a testicular rest tumour on a background of congenital adrenal insufficiency. What is the management of the adrenal rest tumour?
a. Bilateral Orchidectomy
b. Cisplatin-based chemotherapy
c. Lepirudin (GnRH analogue)
d. Steroids

ANS: D

First line treatment = steriods
Then surgery if persistent

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RACP 2022a 21.A patient with type 1 diabetes is calculating his next short-acting insulin dose.
He normally takes insulin glargine 18 units before bed. His pre-breakfast BSL is 12.9 and his target is 6. His normal carbohydrate loading is 1 units rapid-acting insulin for every 10g of carbohydrate. His insulin sensitivity factor is 3.

He anticipates his breakfast has 60g of carbohydrates. What should his pre-
meal insulin be?

a. 6
b. 8
c. 4

ANS: B

2 units + 6 U with breakfast = 8

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RACP 2022a 63.In which format does hormone replacement therapy have the least side
effects?
a. Mini progesterone pill + transdermal oestrogen patch
b. Other options inc non micronised, and oral oestrogens

ANS: A

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RACP 2022a
66.70yo male with Bony met prostate Ca
Ca 2.78 (2.20-2.55)
PTH 7.5 (1.7-7.3)
Urine Ca to Cr 0.41 <0.61
What is the most likely cause of hypercalcemia?
a. Bony erosions
b. Hyperparathyroidism
c. Exogenous Vit D production
d. PTHrP

ANS: B

Demonstrates PTH dependent hypercalcaemia

A, C and D are causes of PTH independent hypercalcaemia

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RACP 2022b 4. What cell type produces testosterone in the testes?
A. Granulosa
B. Leydig
C. Sertoli
D. Theca

ANS: B

Leydig for testosterone
Sertoli for spermatogenesis

Theca cells are a group of endocrine cells in the ovary made up of connective tissue surrounding the follicle. They have many diverse functions, including promoting folliculogenesis and recruitment of a single follicle during ovulation.

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RACP 2022b 20. What are the primary metabolites of testosterone?
A) andostenedione and estrone
B) dihydrotestosterone and oestradiol
C) progesterone and DHEA
D) pregnenolone and something

ANS: B

Testosterone undergoes pre-receptor activation by conversion to potent bioactive metabolites, DHT and estradiol. The steroidogenic enzyme 5α-reductase has two isozymes, types 1 and 2, which form a local androgen amplification mechanism converting testosterone to the most potent natural androgen, DHT

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RACP 2022b 22. Which drugs stop the release of pre-made thyroid hormone?
A. Prednisone and dexamethasone
B. Lithium and iodine
C. Carbimazole and PTU

ANS: B

Treatment include administration of thionamide therapy with methimazole or PTU to stop the synthesis of new thyroid hormone and Iodine to stop the release of pre-formed hormone.

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RACP 2022b 31. Why is HBa1c lower in pregnant women?
A. Iron deficiency
B. Increased cell turnover
C. Presence of foetal haemoglobin

ANS: B

HbA1c reduced due to longer average cell life in pregnancy

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RACP 2021a Q33. What are the two other Rotterdam criteria for PCOS, in addition to an ultrasound finding of polycystic
ovaries?
A. Increased LH:FSH ratio and clinical evidence of hyperandrogenism
B. Increased LH:FSH ratio and primary infertility
C. Oligo/anovulation and clinical evidence of hyperandrogenism
D. Oligo/anovulation and insulin resistance

ANS: C

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RACP 2021a Q76. What complication can you avoid in a patient being given topical oestrogen as opposed to oral oestrogen, in a patient with functional hypothalamic amenorrhea requiring oestrogen replacement?
A. Low BMD
B. Infertility
C. Genital atrophy
D. Endometrial hypertrophy

ANS: D

Transdermal estrogen has been shown to avoid this risk because it delivers a more physiologic release of hormones without the first-pass hepatic metabolism seen with oral estrogen, which increases estrogen levels and risks of endometrial stimulation. Furthermore, when estrogen is delivered transdermally, the metabolic and coagulation impacts are minimized compared to oral estrogen therapy.

A study that supports the use of transdermal estrogen over oral forms to avoid these complications is the ESTHER study, which demonstrated that transdermal estrogen avoids some of the adverse effects associated with oral estrogen, such as venous thromboembolism and other metabolic complications .

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RACP 2021a Q87. What is the most appropriate test to diagnose suspected secondary adrenal insufficiency in an elderly patient?
A. Morning ACTH and cortisol
B. Serum cortisol measured 30 minutes after synthetic ACTH administration (short synacthen test)
C. Serum cortisol measured 30 minutes following insulin-induced hypoglycaemia (insulin tolerance test)
D. Serum cortisol measured 72 hours after synthetic ACTH administration (long synacthen test)

ANS: B

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RACP 2021 Q93/Q94 EMQ – Match the following genetic cancer syndromes from the list of options:
A. MEN1
B. RET
C. VHL
D. SDHA
E. SDHB
F. HPNCC
G. MLH1
H. PTEN
I. PKP2R*
J. NF1*
*Not sure if these two were options.
Q93. Patient presents with pancreatic cancer, pituitary adenoma and hyperparathyroidism

ANS: A
A - Multiple Endocrine Neoplasia 1
B - Multiple Endocrine Neoplasia 2
C - Von Hippel Lindau
D - phaeochromocytoma
E - phaeochromocytoma, paraganglioma
F - Lynch
G - TSG for Adenocarcinoma
H - Endometrial, glial and prostate Ca
I - Arrhythmogenic right ventricular cardiomyopathy (ARVC)
J - Neurofibromatosis

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RACP 2021a Q93/Q94 EMQ – Match the following genetic cancer syndromes from the list of options:
A. MEN1
B. RET
C. VHL
D. SDHA
E. SDHB
F. HPNCC
G. MLH1
H. PTEN
I. PKP2R*
J. NF1*
*Not sure if these two were options.

Q94. Patient presents with retinal angioblastoma, cerebellar hemangioma and a large renal mass.

ANS: C

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RACP 2021b Q111. In a patient with nephrogenic diabetes insipidus due to lithium, adjunctive treatment with amiloride will help by blocking transport of which ion?
A. Calcium
B. Chloride
C. Potassium
D. Sodium

ANS: D

Lithium is cleared in the kidneys
Amiloride is indicated in patients with lithium-induced NDI and continue lithium: blocks lithium entry by blocking the epithelial sodium channels through which lithium gets reabsorbed

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RACP 2021b Q115. What is the site of action of sulfonylurea drugs on pancreatic beta cells?
A. AMP kinase enzyme
B. ATP sensitive potassium channels
C. Glucokinase enzyme
D. Insulin storage vesicles

ANS: B
These drugs exert their hypoglycaemic effects by stimulating insulin secretion from the pancreatic beta-cell. Their primary mechanism of action is to close ATP-sensitive K-channels in the beta-cell plasma membrane, and so initiate a chain of events which results in insulin release.

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RACP 2021b Q138. High titres of antibodies to what target correlate with the presence and severity of extra-thyroidal
manifestations of Graves’ disease?
A. Thyroglobulin
B. Thyroid microsomal
C. Thyroperoxidase
D. Thyrotrophin (TSH) receptor

ANS: D

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RACP 2021b Q143. Where is the principle site of the production of mineralocorticoids?
A. Adrenal medulla
B. Zona glomerulosa
C. Zona fasciculata
D. Zona reticularis

ANS: B

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RACP 2021b Q160. Which hormone released from anterior pituitary is regulated by tonic inhibition?
A. ACTH
B. GH
C. Prolactin
D. TSH

Answer B Prolactin is regulated by tonic inhibition by dopamine

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RACP 2021o 13. Hyperthyroidism in pregnancy (11-12 weeks pregnant). T4 at ULN and T3
slightly elevated with suppressed TSH 0.01. Other than hyperemesis gravidarum,
she has been asymptomatic and uncomplicated pregnancy so far. Tachycardic to
102 bpm, normotensive. Next step in management ?
A. PTU
B. No treatment currently
C. Propranolol and PTU
D. Propranolol

B. No treatment currently.

Rationale:
Subclinical hyperthyroidism is often transient in pregnancy due to the influence of hCG, which can suppress TSH. This is common in early pregnancy and does not always require treatment unless the patient is symptomatic or has significant biochemical hyperthyroidism (very high levels of T3/T4).

The patient is largely asymptomatic aside from mild tachycardia, which can be a normal physiological response to pregnancy or mild hyperthyroidism.

PTU (propylthiouracil) or methimazole is indicated in pregnant women with overt hyperthyroidism to prevent complications. However, in this case, treatment might not be necessary as her thyroid hormone levels are near normal.

Propranolol (D) is used for symptom control in hyperthyroid patients with significant symptoms like severe tachycardia or palpitations, but it is not necessary in asymptomatic or mildly symptomatic patients like this one.
According to the Australian Thyroid Association and Endocrine Society Guidelines, monitoring is recommended for subclinical or mild hyperthyroidism during pregnancy, especially in the first trimester when the physiological rise in hCG can suppress TSH. If symptoms worsen or hormone levels rise significantly, then treatment can be reconsidered.

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RACP 2021o 14. Hyperthyroidism during pregnancy - which thyroid marker/antibody crosses
placenta and can induce foetal hyperthyroidism
a. T3
b. T4
c. Thyrotropin releasing hormone
d. Thyroid stimulating hormone

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RACP 2021o 43. Nurse has stereotyped hypoglycemic symptoms. It always comes after fasting and improves with carbohydrate meals.
BSL 2.4, Cortisone 1500, Low c peptide, insulin just above normal level. What is the most likely diagnosis?
a. Insulinoma
b. Exogenous insulin
c. Cushing’s

Answer C

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RACP 2020 18.
A 24 yo female in her 1st trimester presents with palpitations and ?heat intolerance (symptoms
of hyperthyroidism). She has chemosis and a goitre. Her lab details are: T4 21 (upper limit of
normal), TSH <0.001 (below normal limits), T3 5.1 (normal limits), bHCG 3000+ (way above
normal limits). What therapy do you recommend?
A) Carbimazole
B) PTU
C) Prednisolone
D) Observation

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RACP 2020 27. The use of bisphosphonates after cessation of denosumab is to reduce rapid bone loss and prevent increased fractures of: A) Distal radius B) Intertrochanteric C) Subcapital neck of femur D) Vertebral

Answer D Vertebrae

RACP 2020 28. Subacute thyroiditis shows what pattern of uptake in the affected gland in scintigraph A) Focal increase B) Diffuse increase C) Normal D) Suppressed

Answer D: Suppressed

RACP 2020a Q60 60. In patients with type 1 diabetes, at which life stage is the HbA1c the lowest? A) Childhood (<10years) B) Teenage (11-19yo) C) Young adult (20-35) D) Older adult (>65)

RACP 2020a 70. What is the half life of levothyroxine (thyroxine)? A) 1 day B) 7 days C) 21 days D) 42 days

RACP 2020a 76. An 80M with T2DM was commenced on Metformin by his GP. Which of the following vitmain is he at risk of becoming deficient of? A) B12 B) B6 C) Vit C D) Vitamin D

RACP 2020b 11. What form of thyroid cancer has the worst prognosis A) Anaplastic B) Papillary C) Follicular D) Medullary

RACP 2019a Question 3 A 54 year old woman presents with severe menopausal symptoms, amenorrhoea for 14 months. She is normally fit and well and wants to pursue HRT. What is the best option for managing her symptoms? A. Oestrogen and cyclical progesterone B. Oestrogen with continual progesterone C. Topical oestrogen D. Oral oestrogen only

RACP 2019a Question 15 A 46 year old lady with a background of Addison’s disease presents with flank pain and dysuria. She is normally on hydrocortisone 10mg BD and fludrocortisone 100mg daily. Her temperature is 38.4C, blood pressure is 124/72 mmHg and heart rate is 104 bpm. Her provisional diagnosis is pyelonephritis and she is admitted for intravenous antibiotics. What should be done about her usual medications? A. Add prednisone 20mg daily B. Commence IV hydrocortisone 100mg every 8 hours C. Increase oral hydrocortisone to 20mg BD D. Increase oral hydrocortisone to 20mg BD and fludrocortisone to 200mg daily

RACP 2019a Question 31 An 87 year old man is admitted to hospital with pneumonia and a fall 10 days prior. He is currently in rehabilitation. He has a history of diabetes on metformin 500mg TDS. His HbA1c is 9%. He has peripheral neuropathy and chronic nephropathy with an eGFR of 47ml/min. He has no symptoms of hypoglycaemia or hyperglycaemia. In the last week his BSLs have ranged from 8-15mmol/L. What is the next best step in management? A. Add pioglitazone B. Add insulin C. Add sulphonylurea D. No change to current treatment

RACP 2019a Question 56 Which of the following conditions is it most likely to achieve euthyroidism after effective radioactive iodine therapy? A. Graves’ disease B. Autonomous nodule C. Thyroid cancer D. Multinodular goitre

RACP 2019a Question 62 A fit and well 65 year old woman presents to you with abnormal thyroid function tests on routine blood tests. You repeat the TFTs 3 months later and there is no interval change: TSH: 8 --> 9 mIU/L Free T4: 15 -->16 pmol/L Free T3: 4 --> 4.7 pmol/L What is the most appropriate next step? A. Monitor TFTs 12 monthly B. Selenium replacement C. Thyroid US D. Commence levothyroxine

RACP 2019b Question 29 What activates RANK ligand in osteoblasts? A. PTH B. Calcitonin C. 1-alpha hydroxylase D. Osteoprotegerin

RACP 2019b Question 36 Question 37 In patients with long-standing Type 1 diabetes mellitus, what is the usual cause for hypoglycaemic unawareness? A. Frequent hypoglycaemic episodes B. Increased age C. Larger insulin dose D. Longer diabetes duration

RACP 2019b Question 46 In patients with pituitary apoplexy, what is the most important hormone to replace first? A. Thyroxine B. Hydrocortisone C. DDAVP D. Growth hormone

RACP 2019b Question 54 What is the most likely complication of treatment with growth hormone? A. Diabetes B. Osteoporosis C. Malignancy D. Hypothyroidism

RACP 2018a 21. What is the most common form of thyroid cancer? A. Medullary B.Follicular C. Papillary D. Anaplastic E. Squamous Cell

RACP 2018a 7. A few hours after completing the Auckland marathon a 24-year-old is taken to the Emergency Department by her concerned partner on account of increasing confusion. On assessment she is found to be disoriented in time and place, but has no focal neurological deficit. Other than mild tachypnoea and myalgia in her legs, the remainder of a full clinical examination reveals no abnormal findings. The following biochemistry is obtained: Normal values Sodium (Na) 122 mmol/L [135–145] Plasma osmolality 256 mOsm/L [285–295] Potassium (K) 3.6 mmol/L [3.5–5.5] Urine osmolality 432 mOsm/L [300–900] Creatinine 79 μmol/L [45–90] Glucose 4.8 mmol/L [4.0–5.5] What is the most appropriate way to correct her hyponatraemia? A. Fluid restriction. B. IV hypertonic saline. C. IV normal saline. D. Oral demeclocycline. E. Oral urea.

RACP 2018a A 23-year-old man is found to have elevated plasma metanephrines (5 times upper limit of normal) and a unilateral 4 cm adrenal mass upon investigation for hypertension. He had neck surgery at the age of 11 for thyroid cancer. He is of normal body proportions and has no evidence of mucosal ganglioneuroma. Which gene mutation is the likely cause of his adrenal and thyroid tumours? A. C-RET. B. MEN1. C. NF1. D. SDH-B. E. VHL.

RACP 2018 a 47. A 64-year-old woman with treated hypertension was found to have a right adrenal lesion by CT imaging when investigated for cholelithiasis 2 years previously. The lesion was described as rounded, hypodense (0 Hounsfield units), had a homogeneous appearance, and demonstrated no interval change on a repeat CT imaging 6 months later. Baseline investigations demonstrated normal aldosterone:renin ratio, normal plasma metanephrines, normal 24 hour urinary free cortisol, and a morning cortisol of 44 nmol/L [< 50] following 1 mg dexamethasone the night prior. Two years later, she returns to the medical clinic for re-assessment of this adrenal lesion at the request of her new GP. What is the most appropriate recommendation? A. CT-guided adrenal biopsy. B. MRI adrenals. C. No further investigations. D. PET scan. E. Repeat dexamethasone suppression test.

RACP 2018a 56. A 22-year-old university student was diagnosed with type 1 diabetes 12 years ago and treated with multiple daily injections of insulin (basal insulin glargine plus prandial boluses of insulin aspart). She is seen for follow-up in the diabetes clinic. Measured HbA1c has been > 85 mmol/mol (> 10%) for at least the last 5 years because of non-adherence. However, since she last attended clinic 3 months ago she has been regularly checking pre-meal capillary glucose levels, has been diligently counting carbohydrates and has not missed any basal or prandial insulin injections. Today's HbA1c is 53 mmol/mol (7%). As a consequence of rapidly improving glycaemic control, which diabetes complication is she now most at risk of developing? A. Amyotrophy. B. Foot ulcer. C. Gastroparesis. D. Nephropathy. E. Retinopathy.

RACP 2018 a 57. The product information for alendronate states: Alendronate (brand) "must be taken at least 30 minutes before the first food, beverage, or medication of the day with plain water only." What is the main reason for this advice? A. Alendronate decreases the absorption of calcium. B. Alendronate decreases the absorption of vitamin D. C. Calcium decreases the absorption of alendronate. D. Food decreases the absorption of alendronate. E. Food increases the first pass metabolism of alendronate.

RACp 2018a 65. What is the most common presenting symptom of pituitary apoplexy? A. Diplopia. B. Headache. C. Neck stiffness. D. Vertigo. E. Visual loss.

RACP 2018a 68. To diagnose type 2 diabetes mellitus in an asymptomatic patient, the patient must fulfil two diagnostic criteria, measured on separate days. What is the purpose of this two-stage sequential testing? A. Decreases sensitivity. B. Decreases specificity. C. Increases sensitivity. D. Increases specificity. E. Increases the likelihood of a positive result.

RACP 2018a 75. An 86-year-old lady with hypertension, type 2 diabetes and osteoporosis is found to have mild primary hyperparathyroidism. Her usual medications are metformin, quinapril, hydrochlorothiazide, cholecalciferol and alendronate. In light of the new diagnosis, which of her medications should be discontinued? A. Alendronate. B. Cholecalciferol. C. Hydrochlorothiazide. D. Metformin. E. Quinapril.

RACP 2018b 131.The pharmacokinetic properties of which analogue insulin are largely determined by binding to and dissociation from serum albumin? A. Aspart. B. Detemir. C. Glargine. D. Glulisine. E. Lispro.

RACP 2018b 151.Patients should be considered for investigation for secondary causes of osteoporosis if their z-score is less than −2.0. Assuming normal distribution, what does a z-score of −2.0 indicate? A. A patient with this bone mineral density is in the lowest 1% of age-matched peers. B. A patient with this bone mineral density is in the lowest 2.5% of age-matched peers. C. A patient with this bone mineral density is in the lowest 5% for age-matched peers. D. A patient with this bone density is twice as likely to fracture than other women her age. E. A patient with this bone density is twice as likely to have a secondary cause of osteoporosis compared with a young female.

RACP 2018b 160.In addition to glucagon, which hormones counterregulate hypoglycaemia? A. Adrenaline, cortisol, growth hormone. B. Adrenocorticotropic hormone (ACTH), glucagon-like peptide-1 (GLP-1), renin. C. Aldosterone, vasopressin, triiodothyronine (T3). D. Noradrenaline, ghrelin, corticotropin-releasing hormone (CRH). E. Thyroid-stimulating hormone (TSH), ACTH, testosterone.

RACP 2017 An elderly lady presents to ED and is found to be hyponatraemic. She is on each of the following medications. Which of the following is the most likely cause of her hyponatraemia? A. Candesartan B. Hydrochlorothiazide C. Simvastatin D. Metoprolol E. Trimethoprim

RACP 2017 A 25-year-old pregnant woman presents to the emergency department 12 weeks into her pregnancy with nausea, vomiting, a fine tremor and a HR of 115. There was no goitre or ophthalmopathy. T3     4 (1-3) T4     40 (10-35) TSH      <0.01 (0.5-6) TSH-Receptor Antibody: Negative Anti-TPO Antibody: Negative What is the appropriate treatment for this patient? A. Thyroxine B. Propylthiouracil C. Carbimazole D. Propranolol E. Supportive care

RACP 2017 Which form on insulin has the longest half-life? A. Glargine B. Aspart C. Lispro D. Isophane E. Determir

RACP 2017 A 46-year-old woman with known Addison's disease presents with fever, flank pain and dysuria. Her HR is 102bpm and BP is 120/84 mm Hg. She is admitted with pyelonephritis for IV antibiotics and IV fluids. Her usual medications are Hydrocortisone 10mg BD PO and Fludrocortisone 100 microg daily PO. What should be done with her usual medications on admission?  A. Change her regular PO Hydrocortisone to Prednisone 20mg daily PO B. Change her regular PO Hydrocortisone to Hydrocortisone 100mg TDS IV C. Increase her regular PO Fludrocortisone to 200microg daily PO D. Increase her regular PO Hydrocortisone to 20mg BD PO E. Increase her regular PO Hydrocortisone to 20mg BD PO and her regular Fludrocortisone to 200 microg daily PO

RACP 2017 A 60-year-old female presents with an eight-month history of headaches, galactorrhea and amenorrhoea. She is hypotensive. You are suspecting pituitary apoplexy. Administration of which of the following agents is indicated in your initial management? a) DDAVP b) Adrenaline c) Hydrocortisone d) Cabergoline e) Thyroxine

RACP 2017 A 75-year-old woman with back pain has a DEXA scan to investigate for Osteoporosis. The results are shown below: T-score Lumbar + 1 Radial - 2.6 Right Hip - 2.5 What is the most correct interpretation of the discordant T-scores? A. Corticosteroid-induced Osteoporosis B. Osteoarthritis of the lumbar spine C. Osteomalacia D. Osteoporosis E. Primary Hyperparathyroidism

RACP 2017 A 36-year-old female presents with several months of amenorrhea. She is slightly overweight but not tanned. She is clinically euthyroid with no evidence of hirsutism or visual field disturbance. Laboratory investigation reveals normal thyroid function testing, early morning cortisol, testosterone and prolactin. The patient is noted to have a low oestradiol level and an elevated FSH and LH. What is the most likely diagnosis? A. Microprolactinoma B. Pregnancy  C. Polycystic Ovarian Syndrome D. Prolactinoma E. Premature Ovarian Failure

RACP 2017 Which of the following is most associated with Carbimazole? A. Aseptic Meningitis B. Agranulocytosis C. Interstitial Nephritis D. Sensorineural hearing loss E. Hepatitis

RACP 2017 Within the pancreatic beta islet cell, the sulphonylurea class of medications act upon which of the following? A. AMP kinase enzyme B. ATP sensitive potassium channel C. Insulin vesicle secretion D. Glucokinase E. Voltage Gated Calcium Channel

RACP 2017 Insulin is stored in vesicles within the pancreatic beta cell which is then released in response to rising blood glucose. In which molecular form is insulin stored? A. Monomer B. Hetero-oligomer with c-peptide C. Hetero-oligomer with glucagon D. Dimer E. Hexamer

RACP 2017 Which of the following hormones is secreted by the posterior pituitary gland? A. ACTH B. Arginine Vasopressin C. FSH D. TSH E. Prolactin

RACP 2017 Which of the following describes the target of the monoclonal antibody Denosumab? A. Osteoblasts B. Osteoclasts C. RANK-Ligand D. Estrogen receptors E. PTH Receptor

RACP 2016 RACP Recall Paper 2016 Question 20 What is the most common presenting symptom in SIADH? A. Dizziness B. Altered mental state C. Oedema D. Urinary frequency E. Thirst

RACP 2016 A 75 year old female presents with 24 hours of confusion. She has had 3 days of vomiting and diarrhea which her daughter thinks she developed from her grandson who has been unwell with a similar illness. On examination, she has dry mucous membranes and decreased skin turgor. She has a normal neurological examination. Bloods tests show Na: 124 Urea: elevated Creatinine: elevated Urine osmolality: 500 Urine sodium: 18 What is the most appropriate management of this patient? A. Fluid restriction B. 5% dextrose C. 0.9% NaCl D. Hypertonic saline E. Salt tablets

RACP 2016 Question 77 63year old with hypertension is found to have a 16mm mass in her right adrenal gland on a CT abdomen. Further investigations demonstrate: Aldosterone 530 (elevated) Renin 33 (normal) Ald/Renin ratio 16 (<55) DHEA 4 (normal) Normetanephrines 630 (normal) Metanephrines 330 (normal) 1mg dexamethasone suppression 17 (normal) What is the most likely cause of her mass? A. Adrenal carcinoma B. Adrenal metastasis C. Conn’s adenoma D. Glucocorticoid secretory adenoma E. Non-functioning adrenal adenoma

RACP 2015 Question 2 A 75 year old man with squamous cell cancer of the lung presents with confusion. His serum calcium is 3.85. Other bloods include GGT 308, ALP 218, AST 150, ALT 208 and creatinine 150. He is commenced on IV fluids and the decision is made to also give zolendronic acid. Which of the following is most important to consider when dosing zolendronic acid? A. Patient age B. Degree of hypercalcaemia C. Liver function D. Renal function E. Weight

RACP 2015 Question 5 An 83 year old female was admitted to hospital with a fractured neck of femur. On the third day post-operatively she is found to be hyponatremic. Her sodium was normal on admission. On examination her heart rate is 105 and her blood pressure is 95/65. She has dry mucous membranes. The following investigations are obtained. Sodium 125 Urea 11 Cr 80 Serum osmolality 298 Urine osmolality 288 Urine sodium 15 What is the likely cause of her hyponatremia? A. SIADH B. Hypovolemia C. Drug induced D. ATN E. Rhubarb

2015 Question 18 41 woman hot flushes and amenorrhoea. Nil visual changes. Low TSH. Normal t3 and t4. Low IGF-1. Low FSH and LH, low oestradiol Prolactin 600+ Cortisol normal What is the cause of amenorrhoea? A. Hypothyroidism B. Non-functioning pit macroadenoma C. Primary adrenal insufficiency D. Pituitary macroadenoma E. Rhubarb

2015 Question 23 What is the mechanism of action of Teriparatide? A. Increases osteoblast action B. Reduces osteoclast action C. Increases gastrointestinal absorption of calcium D. Increases hydroxyl-vitamin D E. Increases calcium secretion

2015 Question 10 What is the pathophysiological basis of polycystic ovarian disease? A. Hyperinsulinaemia B. Adrenal androgen excess C. Cortisol excess D. Ovarian cysts E. Endometrial hyperplasia

RACP 2015 Question 13 Increasing incidence of foetal malformations occurs in the offspring of older males because of: A. Increase in incidence of chromosomal abnormalities B. Increase in de novo mutations C. More likely to be using in vitro fertilisation D. Men with medical comorbidities are more likely to delay conception until an older age E. Rhubarb

RACP2015 Question 47 What test has the greatest SPECIFICITY for growth hormone deficiency? A. Random growth hormone level B. Random IGF-1 level C. Growth hormone level after glucose tolerance testing D. Growth hormone level after insulin tolerance testing

RACP Question 48 What is the most common infection secondary to chronic oral steroid use? A. Oral candidiasis B. Herpes simplex C. Bronchopneumonia D. Meningitis E. Rhubarb

RACP 2015 Question An elderly lady (mid 80s) is admitted for treatment of CAP. She is requiring NP oxygen and had fevers, but otherwise is well with BP 120/70 and HR 70. Clinically you think she is euvolaemic. Her Na on admission is 125, with serum osmo 265. Normal Creatinine and Urea. What is your next step in managing her hyponatraemia? A. 0.9% saline infusion B. 3% saline infusion C. Salt tablets D. Fluid restriction E. Observation

RACP 2014 Q9. Which hormone would lead to weight loss? A. Leptin B. Growth hormone C. Cortisol D. Prolactin E. Testosterone

RACP 2014 Question 16 How does insulin exert its effect to reduce BSL? a. transmembrane receptor tyrosine kinase activation b. forms a complex with IGF-1 c. binds to intracytoplasmic receptor d. binds to nuclear receptor

RACP 2014 Question 29 A lady with type one diabetes previously had well controlled disease. She has now had two children and gained weight (BMI 32). She has not had any DKA episodes for years but her HbA 1c has been increasing (now up to 7.8). What is the reason for this? a. poor compliance b. insulin antibodies c. insulin resistance d. poor diet?

RACP 2014 Question 35 A 73 year old female presents with a Colles fracture. Her routine metabolic profile is as follows: Calcium 2.9 mmol/L (2.2–2.6) Albumin 34 g/L (38–48) Creatinine 110 micromol/L (50–90) ALP 250 units/L (<130) PTH 29 pmol/L (2–6) 25-hydroxyvit D 30 mmol/L (>50) Urine Ca:Creat ratio 0.04 (0.04-0.7) CTX 900 ng/L (100–700) P1NP2 100 mcg/L (15–75) (CTX = C-terminal telopeptide of type 1 collagen, a marker of bone resorption) (P1NP2 = Procollagen type 1 N propeptide, a marker of bone formation) What is the best explanation for these results? A. Familial hypocalcuric hypocalcaemia B. Primary hyperparathyroidism C. Primary Vitamin D deficiency D. Pseudohyperparathyroidism E. Renal bone disease

RACP 2014 Question 50 Which of the following agents when used alone is most likely to cause hypoglycaemia? A. Gliclazide B. Pioglitazone C. Metformin D. Sitagliptin E. Exenatide

RACP 2014 Question 5: A 76 year old female is evaluated for osteoporosis. She is currently on vitamin D and calcium medications. She states that she drinks milk regularly and exercises 20 minutes a day. She completed menopause at the age of 46 and never had any HRT. Her UEC, CMP and vitamin D are all normal. Her DEXA scan results are shown below: T score Lumbar spine -1.5 Hip -1.2 What is the management plan? A. Continue calcium and vitamin D B. Commence HRT C. Commence strontium D. Commence bisphosphonate E. Commence raloxifene

RACP 2014 Question 92. 19 year old previously well man presents with polydipsia and nocturia. Tests including calcium, phosphate, eGFR (essentially values in EUC/CMP), glucose, HbA1c and cortisol are normal. The water deprivation test and 2 microg IM synthetic arginine AVP test were performed and are shown below: What is likely diagnosis? A.   Cranial DI B.    Nephrogenic DI C.    Primary polydipsia D.  Partial DI E.   SIADH

RACP 2014 Q95 Which of the following structures labelled below correlates with the following : Neovascularisation

RACP 2014 Q96 Which of the following structures labelled below correlates with the following findings : hard exudate

RACP 2014b Q6 A 27 year old female was commenced on an atypical antipsychotic 2 weeks ago. She develops amenorrhoea and milky discharge from her breasts. Which investigation would help with the diagnosis? A. Serum beta-HCG B. Serum LH and FSH C. Serum prolactin D. Pituitary fossa imaging

RACP 2014b Question 12 What is the first change to occur in diabetic nephropathy? A. Anaemia B. Hyperkalemia C. Increased GFR D. Microalbuminuria  E. Decreased GFR 

RACP 2014b Q29 Which of these hormones acts via an intracellular receptor? A. Insulin B. Glucagon C. Cortisol D. ACTH E. TSH

RACP 2014b Question 37 In the treatment of thyroid storm, which agent prevents the release of pre-formed thyroid hormone, as well as inhibiting the organification of iodine. A Carbimazole B Dexamethasone C Lugol’s Iodine D Propranolol E Propylthiouracil

RACP 2013a Question 50 Sleep-disordered breathing is rare in premenopausal women. This is due to the respiratory stimulating effect of certain hormones. Which of the following hormones provides the greatest stimulation of respiration? a) progesterone b) B – oestradiol c) FSH d) LH e) prolactin

RACP 2013a Question 55 Thyroid opthalmopathy is most strongly associated with which of the following? a) Pretibial myxoedema b) Age 50 years c) Smoking d) Hyperlipidemia e) Peripheral vascular disease

RACP 2013b Question 50 OSA is uncommon in pre-menopausal women. Which hormone stimulates respiratory drive? A. LH B. FSH C. Progesterone D. Oestradiol E. Prolactin

RACP 2013 Question 72 What is the most clinically significant hormone that is affected in thyroid (?pituitary) apoplexy? a) Growth hormone b) ADH c) Cortisol d) Aldosterone e) TSH

RACP 2013b Question 99 Question 99 A 25 year old lady presents to you with new onset palpitations, tremor, heat intolerance, diarrhoea, and significant weight loss despite increases appetite. Extended match questions Options a) TSH b) Free T4 c) Free T3 d) Thyroid Antibodies e) Thyroid US f) Thyroid scan g) FNA of thyroid h) Biopsy i) Thyroidectomy

RACP 2012a QUESTION 25 In a patient with type 1 DM, which of the following counter regulatory hormone is most likely to be reduced? A. Cortisol B. Arenalin C. Growth hormone D. GLP-1 E. Glucagon

Question 100 A 55yo lady has noticed an enlarging neck lump and comes for review with you. TSH is normal. Apart from the large goitre, there were no other significant findings on physical examination. She has a thyroid ultrasound which reports multiple thyroid nodules, one measuring 35mm in size. Options a) TSH b) Free T4 c) Free T3 d) Thyroid Antibodies e) Thyroid US f) Thyroid scan g) FNA of thyroid h) Biopsy i) Thyroidectomy

RACP 2012QUESTION 48 Corticosteroid induced osteoporosis, as compared to postmenopausal osteoporosis, is more likely to be associated with which of the following? A. Asymptomatic vertebral fractures B. Fractures at a higher BMD C. Decreased response to calcium D. Decreased response to bisphosphonates E. Sub trochanteric fractures

RACP 2012 QUESTION 49 An obese 28 yr old woman, with a BMI 31, presents with secondary amenorrhoea. She has Type 2 DM, on metformin 500mg BD. Investigations reveal Prolactin: 580 (<500) Oestrodial: <50 FSH: elevated LH: normal 17-OH Prog: normal What is the most likely cause of her secondary amenorrhoea? A. Polycystic ovarian syndrome B. Primary ovarian failure C. Congenital adrenal hyperplasia D. Prolactinoma E. Pregnancy

RACP 2012 QUESTION 65 A 28 year old presents to her GP for a routine check up. Results of her thyroid function tests are shown: T4 29.6 (mildly raised) TSH 1.2 (within normal limits) What is the cause of her results? A. Graves disease B. Pituitary thyrotrophy C. Presence of herterophile antibodies D. Thyroid hormone resistance E. Exogenous thyroxine intake

RACP 2012b QUESTION 3 You are asked to review a middle-aged gentleman who has recently been gaining weight despite being on maximal biguanide and sulphonylurea for his Type 2 Diabetes Mellitus. His HbA1C is 8.6% and his BMI is 36. Addition of which of the following would be of greatest help in both reducing his weight and improving control of BSL? A. Acarbose B. Pioglitazone C. Insulin glargine D. Exenatide E. Sitagliptin

RACP QUESTION 44 A 45 year old patient is admitted to ICU with systemic inflammatory response syndrome, secondary to Pancreatitis associated with gallstones. Which form of nutrition is best? A. Intravenous fluids B. PEG feeding C. Gastrostomy D. Total parenteral nutrition E. NG/NJ tube feeding

RACP 2012b QUESTION 45 A 30 year old lady with Type 1 Diabetes Mellitus is currently on 10 units of short acting insulin with meals and 30 units of long acting insulin at night. She is admitted 1 day prior to laparotomy for insulin management. Which regime is best? A. Insulin infusion at 2 units/hour B. Insulin infusion at DKA protocol at 5 units/hour C. Reduce her basal-bolus regimen by half D. Subcutaneous Insulin sliding scale E. Omit everything

RACP 2012b QUESTION 73 58 year old male with hypertension for the last 2 yearsis referred due to difficulty achieving optimal BP targets. Blood tests prior to anti-hypertensive treatment are as follows; Cr 67 K 3.2 Renin 102 Aldosterone 1108 Aldosterone:renin ratio 10.8 What is the diagnosis? A. Phaemchromocytoma B. Renovascular Disease C. Cushing Syndrome D. Primary Aldosteronism E. Congenital Adrenal Hyperplasia

RACP 2012b QUESTION 98 A 67 year old lady presented with fatigue, lethargy and pre-tibial pitting oedema. She had a history of Hashimotoʼs hypothyroidism, on 300mcg thyroxine daily. She was obese, BMI 36 kg/m2 [25 -30]. Her thyroid function tests revealed: Free T4 8 (Low) [10 - 25] Free T3 2 (Low) [4 - 8] TSH 65 mIU/L (High) [0.4 – 5.0] What is the best explanation for her abnormal thyroid tests: A. Inadequate thyroxine dosing B. Malabsorption C. Interaction with food D. Poor compliance / adherence E. Thyroid hormone resistance

RACP 2011a Question 16 75 year old man with a history of back pain had a DEXA scan with the following T scores: Lumbar spine +0.5 Hip -2.5 Radius -2.5 What is the best explanation for the discordant T score of the lumbar spine? A. Glucocorticoid induced osteoporosis B. Osteomalacia C. Osteoarthritis of the lumbar spine D. Osteopetrosis E. Primary hyperparathyroidism

RACP 2011a Question 31 Metformin is used as first line therapy in type 2 diabetes mellitus for many patients. What is the most important action by which Metformin reduces BSLs? A. Increased insulin receptor expression B. Decreased hepatic glucose production C. Increased insulin secretion D. Weight loss improving insulin sensitivity E. Delayed gastric emptying

RACP 2011 Question 40 In obese patients which sign has the highest likelihood ratio for representing corticosteroid excess? A. Abdominal striae B. Buffalo Hump C. Hirsutism D. HTN E. Proximal myopathy

RACP 2011b Question 9 A 78 year old lady was admitted with ischaemic chest pain and underwent coronary angiography. 24 hours later, she developed a tremor and palpitations and was found to be in rapid atrial fibrillation. She has a small nodular goiter with no retrosternal extension on examination. Her T4 and T3 are raised with a low TSH. What is the most likely cause? A. Hyperfunctioning nodule B. Contrast induced thyroiditis C. Graves disease D. Subacute thyroiditis E. Hashimoto’s thyroiditis

RACP 2011b Question 19 Mechanism of steroid induced osteoporosis is: A. Increased apoptosis of osteoblasts B. Increased intestinal Ca2+ absorption C. Increase parathyroid hormone D. Decreased production of osteoprotegerin E. Decreased renal tubular Ca secretion

RACP 2011b Question 56 A 35 year old obese man with type II diabetes mellitus is on a biguanide and metformin. Despite this, his blood sugar level (BSL) control is poor with an HbA1c of 8.6% and increased weight (BMI 32 kg/m2). Which of the following will result in both weight loss and improvement in his HbA1c? A. Acarbose B. Exenatide C. Pioglitazone D. Rosiglitazone E. Sitagliptin

RACP 2011b Question 73 Q73. 21 year old female presents with secondary amenorrhoea and hirsutism. Her BMI is 29. The following lab results are provided: LH 7 FSH 2 Oestrogen 150 17-OH Progesterone: basal 14 1 hour post synacthen 52 prolactin 530 What is the cause? A. Prolactinoma B. Hypogonadotrophic C. hypogonadism D. Non-classical congenital adrenal hyperplasia E. Turner’s syndrome PCOS

RACP 2011b Question 77 77. In a 35 y/o male with a five year history of poorly controlled diabetes, which of the following is the strongest reason to check an anti-GAD antibody level? A. Predict likelihood of Type 1 DM B. Predict the severity of Type 2 DM C. Assess insulin reserve D. Assess residual pancreatic islet cell function E. Predict likelihood of associated Coeliac Disease

RACP 2011b Q81 A 65 year old lady with a 15 year history of type 2 DM is on metformin and sulphonylurea for long time. Past 2 yrs blood tests reveal worsening glycaemic control with HbAC1 9.2%. Fasting BSLs are 5-9 mmol/L and post prandials are 9-16 mmol/L. Her weight is stable and she reports good compliance. What is the best explanation? A. Impaired first phase insulin response B. Decreased insulin sensitivity C. Decreased insulin secretion D. Change in lean body mass E. Poor compliance

RACP 2011b Question 83 Most adrenal masses found incidentally on CT are nonfunctioning, but sometimes subclinical Cushings is present. What is the best test for exclusion of this? A. 8am serum cortisol level B. Low dose dexamethasone suppression test C. High dose dexamethasone suppression test D. Plasma ACTH level E. Glucose tolerance test

RACP 2011b Question 92 A 40 year old man with a 20 year history of type one diabetes mellitus presents with difficulty flexing and extending his fingers. There is thickened skin over the dorsum of the hands with palpable thickened tendon sheaths. There is no digital pitting or loss of distal finger subcutaneous tissue. What is the most likely diagnosis? A. Hypothyroidism B. Limited scleroderma C. Haemachromatosis D. Diabetic cheiroarthropathy E. Amyloidosis

RACP 2010 QUESTION 2 Increased release of which of the following hormones is most likely to increase food intake? A. Adiponectin. B. Ghrelin. C. Glucagon-like peptide 1 (GLP-1). D. Leptin. E. Peptide YY

RACP 2010 Question 15: Which is the following best explains early morning low testosterone levels in a nondiabetic obese male? A. Low physical activity B. Low serum binding globulin C. Decreased steroidogenesis by adrenals D. Increased peripheral aromatase conversion E. Increase Insulin resistance

RACP 2010 Question 37: Which is the most common side effect of high dose prednisone? a) Depression b) Mania c) Psychosis d) Insomnia e) Delirium

RACP 2010 Question 41: What is the main reason for tight BSL control in a woman with gestational diabetes? a) To prevent neonatal birth defects. b) To reduce miscarriage rates c) To reduce macrosomia d) To reduce the risk of diabetes mellitus in the mother e) To reduce the risk of diabetes mellitus in the child

RACP 2010 Question 51: Which of the following would give the greatest level when measured at midnight in comparison to its 8am level.  a) adrenalin b) cortisol c) insulin d) growth hormone e) testosterone

RACP 2010 Question 66: Patient has panhypopituitarism and is currently on thyroxine 100mcg daily, prednisone 5mg daily and testosterone replacement. The addition of which of the following medications is likely to precipitate an Addisonian crisis? a) Dexamethasone b) Hydrochlorothiazide c) Rifampicin d) Ritonavir e) Spironolactone

RACP 2010 Question 51: An 81 year-old woman presents with new and ongoing seizures and confusion. She was recently discharged following an admission with Herpes Zoster, treated with acyclovir, and significant post-hepatic neuralgia and nausea. Her current medications are codeine, amytriptiline and metclopromide. A complete blood panel is shown which was largely unremarkable apart from Na+ = 109. Urinary sodium = 58 Osmolality = 550 (No other urine results given) What is the most appropriate initial treatment? a) 0.45% saline b) 0.9% saline c) 3% saline d) Fluid restriction e) Frusemide

RACP 2010 Question 63: In a patient with a 8mm prolactinoma, what is the most likely (?presenting) symptom? a) amenorrhoea b) galactorrhoea c) headache d) visual disturbance e) low libido

RACP 2010 Question 80: 48yo type II DM man, diet controlled, obese, with fasting BSLs at home ranging from 9à12, with postprandial 6 à 11. Most likely cause of these BSL trends? a) midnight snacking b) overnight hepatic gluconeogenesis c) islet cell failure d) rebound hyperglycaemia

RACP 2010 QUESTION 83: What is the reason for measuring thyroid stimulating antibody levels in the third trimester of pregnancy in a woman with Graves disease? A To check whether it is appropriate to withdraw anti thyroid medication B To assess for foetal goitre C For titration of antithyroid medications D To assess the risk of post partum thyroiditis E To assess the risk of neonatal thyrotoxicosis

RACP 2010 Q98 42 yo man with Type 1 diabetes for 20yrs. He has nephropathy. Recent onset of trouble using his fingers with thickening of the tendons and skin. He has normal skin on his arms. What is the cause? a) Limited scleroderma b) Amyloid c) Diabetic cheiroarthropathy d) RA

RACP 2009a Question 5 What predisposes someone to a greater risk of developing type 1 diabetes mellitus a) Father with type 1 diabetes b) Mother with type 1 diabetes c) Autoimmune thyroiditis d) BMI >40 e) Previous gestational diabetes

RACP 2009a Question 8 A 72 year old man presents with hypotension, lethargy and decreased libido. Upon standing his BP drops from 130/80 to 100/70. He has an MRI brain performed which shows a pituitary macroadenoma. A deficiency in what is most likely to explain the reduced libido? A) ACTH. B) Growth hormone. C) Lutenising hormone. D) Prolactin. E) FSH.

RACP 2009a Question 14 In diabetic ketoacidosis, what is the mechanism of hyponatraemia? A. syndrome of inappropriate antidiuretic hormone secretion B. extrarenal sodium loss via vomiting C. renal losses of sodium through polyuria D. metabolic acidosis E. Hyperosmolar extracellular space leading to water movement out of cells.

RACP 2009a Question 21 The best clinical explanation for the glucose-lowering effect of exenatide (GLP-1 analogue) is a) Delayed gastric emptying b) Increased glucagon secretion c) Increased insulin secretion from pancreatic beta-cells d) Inhibition of DPP-IV e) Decrease breakdown of endogenous incretins

RACP 2009a Question 36 A 55 yr old male with 12 yr history of type II DM complaints of pain in his feet. It is worse at night. He describes it as a burning sensation. He can’t tolerate bed clothes on his feet. On examination temperature sensation is decreased in the forefoot, ankle jerks are present. His HbA1c is 9.1 % What is the most likely pathological finding? A) Patchy ischaemic infarction of nerves B) Loss of myelin in large fibres C) Decreased density of epidermal nerves D) Thinning of capillary basement membrane E) Loss of cell bodies in dorsal root ganglion

RACP 2009a Question 51 Osteonecrosis of the jaw is a rare disorder of bisphosphanates. What is the greatest risk factor for ONJ? a) Advanced age b) Mode of delivery . IV vs PO c) Total exposure dose d) Lack of Vit D and calcium co supplementation

RACP 2009b QUESTION 10 Which of the following is the most important reason to measure thyroid stimulating antibodies in the third trimester of pregnancy in a woman with Grave’s disease? A. Allow withdrawal of antithyroid medication B. Predict risk of flare of thyrotoxicosis post‐partum C. Detect foetal goitre D. Predict risk of neonatal thyrotoxicosis E. Guide dose adjustment of antithyroid medication

RACP 2009b QUESTION 14 What is the cause of hyponatremia in patients presenting with ketoacidosis? A. Intracellular shift of sodium B. Syndrome of inappropriate ADH secretion C. Increased urinary loss of sodium D. Extracellular shift of water due to hyperosmolarity E. Gastrointestinal loss due to vomiting

RACP 2009b QUESTION 22 A 34 year old woman presents with headache and a BP of 220/120. The following investigations were performed: Urine: Cortisol 74 Adrenaline 87 Noradrenaline 570 Dopamine 3300 Normetanephrine 450 Metanephrine 383 Plasma: Aldosterone 117 Renin 5.0 K 3.8 What is the most likely diagnosis? A. Pheochromocytoma B. Cushing’s syndrome C. Carcinoid D. Conn’s syndrome E. Essential hypertension

RACP 2009b QUESTION 26 A 60 year old man with diabetes complains of intermittent regurgitation of food eaten a few hours prior. There is no loss of weight. His wife complains of him having halitosis. He occasionally has dysphagia of solid food which he localises to his throat. Which of the following is the most likely diagnosis? A. Eosinophilic oesophagitis B. Achalasia C. Gastroesophageal reflux D. Pharyngeal pouch E. Schatzki ring

RACP 2009b QUESTION 38 A 54 year old woman presents with a lump in her neck, increasing in size over 3 weeks. Examination reveals a diffusely enlarged thyroid and a prominent 2cm thyroid nodule in the right lower lobe. fT3 normal fT4 normal TSH normal Anti TPO 1:400 Anti TG negative Ultrasound demonstrates a mixed solid and cystic nodule in the lower right pole of the thyroid The most appropriate next step is: A. Observe B. CT neck C. Repeat thyroid ultrasound in 6 months D. Fine needle aspirate of nodule E. Thyroxine to suppress TSH

RACP 2009b QUESTION 90 A 25 year old male comes to see you because he is concerned about his infertility. He is 1.8 metres tall and weighs 70 kg. He has no facial hair, but has axillary and pubic hair. Both testicles are in situ and are of normal size measuring 2 mL. His stretched penile length is 4cm. Testosterone 1.2 LH 0.1 What is the likely cause of his infertility? A. XXY B. Hypogonadotrophic hypogonadism C. Primary gonadal failure D. Macroprolactinoma E. Previous mumps orchitis

RACP 2009b QUESTION 97 A 38 year old lady presenting to ED with her first episode of diabetic ketoacidosis has a pH of 7.20 and BSL 25. There are no known precipitating factors. She takes several medications at present – hydrochlorothiazide and atenolol for hypertension, olanzapine for post partum depression, and ranitidine for reflux. Which of these is most likely to have contributed to her current condition? A. Excess alcohol intake B. Hydrochlorothiazide C. Olanzapine D. Atenolol E. Ranitidine

RACP 2008a QUESTION 18 In a normal person, which of the following is most likely to cause a decrease in circulating growth hormone concentration? A. Slow wave sleep. B. Hyperglycaemia. C. Protein meal. D. Exercise. E. Sepsis.

RACP 2008a QUESTION 28 Glucagon-like peptide–1, secreted postprandially by the L-cells in the intestine, increases which of the following? A. Gastric emptying. B. Body weight. C. Insulin secretion. D. Hepatic glucose output. E. Insulin sensitivity.

RACP 2008a QUESTION 41 Which of the following hormones is likely to be at its highest level during the luteal phase compared with any other time of the menstrual cycle? A. Luteinising hormone (LH). B. Follicle stimulating hormone (FSH). C. Progesterone. D. Oestradiol. E. Testosterone.

RACP 2008a QUESTION 54 In the average person, which of the following accounts for the greatest amount of daily energy expenditure? A. Fat mass metabolism. B. Basal metabolic processes. C. Spontaneous physical activity (fidgeting). D. Physical exercise. E. Thermic effect of food.

RACP 2008b QUESTION 2 A 31-year-old woman presents with an absence of menstrual periods since stopping the oral contraceptive pill five months ago. She has the following investigations: Weight 80.4 kg Height 1.70 m Body Mass Index 27.8 kg/m2 Prolactin 2566 mIU/L [60 – 550 mIU/L] Luteinising hormone (LH) <1.0 IU/L [3.0 – 12.0 IU/L] Follicle-stimulating hormone (FSH) <1.0 IU/L [2.0 – 10.0 IU/L] Oestrogen 35 821 pmol/L [100 – 2400 pmol/L] Testosterone 3.1 nmol/L [0.5 – 2.5 nmol/L] Which of the following is the most likely explanation? A. Prolactinoma. B. Polycystic ovarian syndrome (PCOS). C. Pregnancy. D. Congenital adrenal hyperplasia. E. Hydatidiform mole.

RACP 2008b QUESTION 14 Which one of the following most frequently causes hypoglycaemia in patients with diabetes? A. Pioglitazone. B. Glibenclamide. C. Metformin. D. Acarbose. E. Sitagliptin.

RACP 2008b QUESTION 17 A 52-year-old man with type 2 diabetes has been non-specifically unwell for a week. He underwent resection of a craniopharyngioma nine months ago. He is maintained on replacement therapy with desmopressin nasal spray, testosterone decanoate injections, oral hydrocortisone and thyroxine. He presents to hospital with a reduced level of consciousness. Systolic blood pressure is 70 mmHg and axillary temperature is 35oC. Investigations reveal the following results: Serum sodium 136 mmol/L [136 – 148 mmol/L] Serum potassium 5.2 mmol/L [3.6 - 5.5 mmol/L] Serum bicarbonate 30 mmol/L [22 – 32 mmol/L] Serum urea 8 mmol/L [3 - 8 mmol/L] Serum creatinine 120 μmol/L [30 – 120 μmol/L] Random glucose 18 mmol/L [3.5 - 7.8 mmol/L] Free L-thyroxine 9.8 pmol/L [10.0 – 26.0 pmol/L] What is the most likely cause of his acute presentation? A. Raised intracranial pressure due to tumour recurrence. B. Myxoedema coma. C. Glucocorticoid deficiency. D. Diabetes insipidus. E. Hyperosmolar non-ketotic coma.

RACP 2008b QUESTION 41 A 60-year-old male presents with central weight gain, hypertension, and diabetes. He has a history of asthma treated with inhaled corticosteroids. He drinks two standard drinks of alcohol/day. On examination he has central obesity, thin skin, and proximal muscle weakness. The following test results are obtained: 24 hour urinary free cortisol 1400 nmol/day [<400 nmol/day] 0900 plasma adrenocorticotrophic hormone (ACTH) 15 pmol/L [3 – 20 pmol/L] Magnetic resonance imaging (MRI) pituitary normal Which of the following is the most likely cause of this man’s presentation? A. Exogenous glucocorticoid administration. B. Pseudo-Cushing’s syndrome. C. Cushing’s disease. D. Ectopic Cushing’s syndrome. E. Cortisol producing adrenal adenoma

RACP 2008b QUESTION 49 A 35-year-old woman with type 1 diabetes since age 14 years is reviewed. She reports three episodes of hypoglycaemia with levels <3.0 mmol/L during the night in the last month. There have also been a number of hypoglycaemic episodes in the late morning. Recent results show: Weight 55 kg Fasting plasma glucose 12.3 mmol/L [4.0 – 6.0 mmol/L] Hb A1c 6.9% [<6%] Urine microalbumin:creatinine ratio 0.1 [<3.5] Current insulin regimen: Neutral Protamine Hagedorn (NPH) insulin 14 units before breakfast and 12 units before bed Insulin aspart 4 - 6 units before breakfast and lunch and 8 - 10 units before dinner Which one of the following modifications to her insulin regimen would be most effective in optimising her glycaemic control? A. Omit evening NPH insulin. B. Change time of evening NPH insulin to before evening meal. C. Reduction of evening aspart insulin by 10%. D. Introduction of insulin glargine at a dose of 12 units in place of evening NPH insulin. E. Substitution of both doses of NPH insulin with one pre-breakfast dose of 20 units of insulin glargine.

RACP 2008b QUESTION 69 A 30-year-old woman presents three months postpartum with weight loss, tremor, palpitations and heat intolerance. On clinical examination she is tachycardic, has a fine finger tremor, lid retraction, lid lag but no goitre. Thyroid function test results are: Free T4 35 pmol/L [10 – 24 pmol/L] Free T3 12.0 pmol/L [3.8 - 6.8 pmol/L] Thyroid-stimulating hormone (TSH) <0.01 mIU/L [0.40 – 4.00 mIU/L] Anti thyroid peroxidase antibodies Positive Thyroid scintiscan is shown below. Which of the following is the most likely cause of this woman’s thyrotoxicosis? A. Factitious thyrotoxicosis. B. Postpartum thyroiditis. C. Graves disease. D. Subacute thyroiditis. E. Iodine-induced thyrotoxicosis.

RACP 2008b QUESTION 75 Which of the following agents is most likely to induce weight loss when used to treat type 2 diabetes mellitus? A. Acarbose. B. Glargine insulin. C. Glimepiride. D. Metformin. E. Pioglitazone.

RACP 2008b QUESTION 78 Use of which of the following drug classes is most likely to lead to the onset of type 2 diabetes? A. Atypical antipsychotic drugs. B. Beta-blockers. C. Thiazides. D. Monoamine oxidase inhibitors. E. Tricyclic antidepressants.

RACP 2008b QUESTION 89 A 65-year-old man with a history of paroxysmal atrial tachycardia who has been treated with amiodarone for five years presents with worsening palpitations. Thyroid function tests show the following results: FT4 45 pmol/L [10 – 24 pmol/L] FT3 10.0 pmol/L [2.5 – 6.0 pmol/L] Thyroid-stimulating hormone (TSH) <0.03 mIU/L [0.4 – 4.0 mIU/L] He is commenced on carbimazole 10 mg tds but fails to improve and three weeks later his thyroid function tests are as follows: FT4 100 pmol/L FT3 14 pmol/L TSH <0.03 mIU/L Which of the following is the most likely cause of this patient’s thyrotoxicosis? A. Graves Disease. B. Type 1 (iodine-induced) amiodarone induced thyrotoxicosis. C. Type 2 (inflammatory) amiodarone induced thyrotoxicosis. D. Subacute viral thyroiditis. E. Toxic multinodular goitre.

RACP 2008b QUESTION 90 A 43-year-old woman presents with a six month history of hypertension which has been difficult to control. She is now taking three agents for her blood pressure control. She has a serum potassium of 2.7 mmol/L [3.6 - 5.2 mmol/L] and you are concerned about primary hyperaldosteronism (Conn’s syndrome). Which of the following medications is most likely to interfere with the interpretation of an aldosterone:renin ratio result? A. Amlodipine. B. Enalapril. C. Spironolactone. D. Metoprolol. E. Alpha-methyl-dopa.

RACP 2007a QUESTION 5 Which of the following counter-regulatory factors is released earliest in response to hypoglycaemia? A. Adrenaline. B. Cortisol. C. Noradrenaline. D. Growth hormone. E. Glucagon.

RACP 2007a QUESTION 18 Which of the following has the greatest effect on peak bone mass? A. Pubertal age. B. Childhood calcium intake. C. Genetic factors. D. Childhood physical activity. E. Body weight.

RACP 2007a QUESTION 36 A 16-year-old male presents with short stature. Which of the following findings is most suggestive of growth hormone deficiency? A. Reduced growth velocity. B. Decreased bone age. C: Height below the 3rd centile. D. Delayed puberty. E. Increased body weight.

RACP 2007a QUESTION 45 A patient presenting to the Emergency Department is thought to have acute intermittent porphyria. Which of the following is most suggestive of an alternative diagnosis? A. Ileus. B. Hypertension. C. Fever. D. Urinary retention. E. Tachycardia.

RACP 2007a QUESTION 48 In a normal person, which of the following is most likely to cause a decrease in circulating growth hormone concentration? A. Slow wave sleep. B. Hyperglycaemia. C. Protein meal. D. Exercise. E. Sepsis.

RACP 2007a QUESTION 62 In a patient with Type 2 diabetes which of the following co-existing clinical situations is the strongest contraindication to the use of a thiazolidinedione drug? A: Serum creatinine 200µmol/L. B: Proliferative diabetic retinopathy. C: Severe congestive cardiac failure. D: Peripheral vascular disease. E: Fatty liver disease.

RACP 2007b QUESTION 14 A 65-year-old woman with longstanding rheumatoid arthritis and osteoporosis presents with a mid thoracic crush fracture. She has a history of two previous crush fractures and has been taking alendronate 70mg weekly for three months. She has a normal serum calcium, phosphate, albumin and 25 hydroxy-vitamin D. She has taken prednisolone in the past. Which of the following treatments is most appropriate for future fracture prevention? A. Continue alendronate and add raloxifene. B. Cease alendronate and commence intravenous pamidronate. C. Continue alendronate. D. Cease alendronate and commence strontium ranelate. E. Cease alendronate and commence risedronate

RACP 2007b QUESTION 15 In patients with type 1 diabetes mellitus the greatest benefit in using a long-acting insulin analogue is in reducing which of the following? A: Diabetic retinopathy. B: Nocturnal hypoglycaemia. C: Insulin hypersensitivity. D: Preprandial hyperglycaemia. E Microalbuminuria.

RACP 2007b QUESTION 16 A 25-year-old has adrenocorticotrophic hormone -dependent Cushing’s Syndrome. He has a normal MRI scan of the pituitary fossa. Which of the following is the most useful next investigation? A. High dose dexamethasone suppression test. B. CT scan adrenal glands. C. Petrosal sinus sampling. D. Thoracic CT scan. E. Corticotrophin Releasing Hormone (CRH) test.

RACp 2007b A patient with long standing type 1 diabetes presents has the appearances on fundoscopy shown below. Which of the following therapeutic strategies is most likely to preserve his long-term vision? A. Tight blood pressure control. B. Aspirin. C. Tight blood glucose control. D. Vitrectomy. E. Pan-retinal photocoagulation.

RACP 2007b QUESTION 44 A 51-year-old man presents with unstable angina. His mother died at age 58 years as a result of a myocardial infarction and his 48-year-old brother, who smoked heavily and was overweight, survived a heart attack two years previously. After discharge he consults the internet and, when reviewed, expresses concern that he may have familial hypercholesterolemia and that there could be a risk that his son, aged 11 years, may also be at risk of heart attack at an early age. What finding would give you greatest concern that the patient is correct and that is a need to consider further the possibility that other members of his family are at risk of early onset coronary vascular disease? A. Arcus cornealis. B. Tendinous xanthomata. C. LDL (lowdensity lipoprotein) cholesterol of 7.8 mmol/litre [<3.0 mmol/L]. D. Xanthelasma. E. His son’s LDL cholesterol level is 1.5 standard deviations above the mean for 11 year olds.

RACP 2006a QUESTION 20 Diabetic neuropathic arthropathy is most likely to affect which of the following areas? A. Knee. B. Mid-foot. C. 1st metatarsophalangeal joint. D. Elbow. E. Ankle.

RACP 2006a QUESTION 27 Which of the following drugs used in diabetes treatment is most likely to cause hypoglycemia? A. Repaglinide. B. Metformin. C. Acarbose. D. Rosiglitazone. E. Orlistat.

RACP 2006a QUESTION 31 A 35-year-old man presents with several weeks of generalised unwellness, epigastric pain, vomiting and headaches. He has no past medical history of note. He has a smoking history of 15 pack years and uses daily cannabis. He has been holidaying at the beach for the summer and is tanned. He is mildly dehydrated. The rest of the physical examination is unremarkable. Blood tests show: sodium 139 mmol/L [138-145] potassium 5.4 mmol/L [3.5-5.2] corrected calcium 3.10 mmol/L [2.15-2.57] phosphate 1.50 mmol/L [0.87-1.45] urea 10.4 mmol/L [3.5-8.0] creatinine 0.32 mmol/L [0.05-0.12] parathyroid hormone 0.6 pmol/L [1.6-6.2] His chest X-ray is shown below. What mechanism best explains the hypercalcaemia? A. Secretion of parathyroid hormone-related peptide (PTHrP). B. Increased bone resorption. C. Increased 1,25(OH)2-vitamin D synthesis. D. Reduced renal clearance of calcium. E. Mineralocorticoid deficiency

RACP 2006a QUESTION 49 The coupling of osteoblast and osteoclast function is mainly related to the action of which of the following factors? A. Tumour Necrosis Factor (TNF). B. Parathyroid hormone (PTH). C. Receptor activator of NFKB (RANK) ligand. D. 1,25 (OH)2 cholecalciferol. E. Oestradiol.

RACP 2006b QUESTION 9 A 45-year-old woman is admitted after being found unconscious. Her plasma glucose is 1.5 mmol/L. The following results are obtained: Plasma insulin 105 pmol/L [<80 fasting] Plasma C-peptide 650 pmol/L [250-700] CT (computed tomography) pancreas Normal Which of the following best explains these findings? A. Addison’s disease. B. Insulin administration. C. Alcohol ingestion. D. Insulinoma. E. Growth hormone deficiency.

RACP 2006b QUESTION 50 A 25-year-old woman with no significant past medical history presents with weight gain, depression, easy bruising and proximal muscle weakness. On examination she has a plethoric complexion, central obesity with striae and a proximal myopathy. Investigations reveal low plasma concentrations of cortisol and adrenocorticotrophic hormone (ACTH). Which of the following is the most likely diagnosis? A. Cushing’s disease. B. Pseudo-Cushing’s syndrome. C. Factitious Cushing’s syndrome. D. Ectopic ACTH syndrome. E. Cortisol-producing adrenal adenoma.

RACP 2006b QUESTION 53 A 27-year-old woman presents with weight loss, tremor, palpitations and pain and tenderness over her thyroid. The following results are obtained: Free T4 75 pmol/L [10-24] Free T3 25 pmol/L [2.5-6.5] thyroid-stimulating hormone (TSH) <0.03 mIU/L [0.4-4.0] erythrocyte sedimentation rate (ESR) 105 mm/hour [<10] A thyroid scintiscan is awaited. In the meantime, in addition to beta blockers, which of the following is the most appropriate first line treatment for her condition? A. Prednisone. B. Carbimazole. C. Radioiodine. D. Propylthiouracil. E. Diclofenac.

RACP 2006b QUESTION 76 In a woman with Graves disease, which of the following is associated with an increased relative risk of developing Graves ophthalmopathy? A. Pregnancy. B. Young age. C. High titre microsomal antibodies. D. Smoking. E. Previous thyroid surgery

RACP 2006b QUESTION 90 An 18-year-old woman presents with hirsutism. The following results are obtained: Which of the following is the most likely explanation for her hirsutism? A. Polycystic ovarian syndrome. B. Androgen secreting ovarian tumour. C. Cushing’s syndrome. D. Late onset congenital adrenal hyperplasia. E. Adrenocortical carcinoma.

RACP 2005a QUESTION 4 Diabetic neuropathic arthropathy is most likely to affect which of the following areas? A. Knee. B. Mid-foot. C. 1st metatarsophalangeal joint. D. Elbow. E. Ankle.

RACP 2005a QUESTION 6 Which of the following mechanisms best describes the mode of action of the sulphonylurea class of drugs? A. Stimulates insulin synthesis. B. Enhances insulin binding to the beta cell insulin receptor. C. Stimulates insulin secretion. D. Stimulates conversion of proinsulin to insulin and C-peptide. E. Stimulates beta cell proliferation.

RACP 2005a QUESTION 17 In addition to decreased gastrointestinal calcium absorption, by which of the following mechanisms is prednis(ol)one most likely to cause net bone loss in a 65-year-old man? A. Increased renal calcium loss. B. Reduced 1,25 (OH)2 vitamin D formation. C. Reduced testosterone production. D. Direct suppression of osteoblast function. E. Reduced adrenal androgen production.

RACP 2005a QUESTION 21 A 60-year-old man with a five-year history of type 2 (non-insulin-dependent) diabetes mellitus presents for a routine checkup. The most appropriate screening test for the presence of diabetic nephropathy is: A. serum creatinine level. B. spot urine albumin concentration. C. 24 hour urine protein excretion. D. spot urine albumin/creatinine ratio. E. 12 hour urinary albumin excretion rate.

RACP 2005a QUESTION 33 A 36-year-old woman has a very strong family history of premature coronary disease. Physical examination is normal. Fasting lipid profile reveals: total cholesterol 9.5 mmol/L [2.5-5.2] high-density lipoprotein (HDL) cholesterol 1.5 mmol/L [0.9-1.8] triglycerides 2.00 mmol/L [0.10-1.85] Which abnormality is most likely to be present? A. apoB 3500 mutation. B. Cholesteryl ester transfer protein (CETP) deficiency. C. Hypoalphalipoproteinaemia. D. Low-density lipoprotein (LDL) receptor defect. E. Lecithin:cholesterol acetyltransferase (LCAT) deficiency.

RACP 2005a QUESTION 50 The deterioration in glycaemic control over time seen in patients with type 2 (non-insulin- dependent) diabetes mellitus is primarily due to: A. medication non-compliance. B. increasing insulin resistance. C. increasing obesity. D. decreasing insulin secretion. E. reduced energy expenditure.

RACP 2005a QUESTION 56 Carbimazole acts predominantly by inhibiting which of the following mechanisms? A. Sodium/iodide (Na/I) symporter. B. Thyroid peroxidase activity. C. Binding of thyroxine to thyroid binding globulin. D. Thyroglobulin synthesis. E. 5’-deiodinase activity.

RACP 2005b QUESTION 3 Which of the following diabetic neurological complications is most likely to improve with time? A. Diabetic amyotrophy. B. Orthostatic hypotension. C. Gustatory sweating. D. Loss of deep tendon reflexes. E. Painful peripheral neuropathy.

RACP 2005b QUESTION 4 An 84-year-old female nursing home resident is ambulant but rarely goes outside. She is thin, eats little and has reflux oesophagitis. Medical history includes mastectomy and radiation therapy for breast cancer at age 60 years. There is a past history of deep venous thrombosis (DVT). Dual-energy X-ray absorptiometry (DEXA) scan reveals a t score of -2.2 at the spine and -3.0 at the femoral neck. Serum calcium is normal. In addition to calcium supplementation, which of the following is the most appropriate initial therapy for her osteoporosis? A. Alendronate. B. Calcitonin. C. Vitamin D. D. Oestrogen. E. Raloxifene.

RACP 2005b QUESTION 21 A 40-year-old man presents with weight loss, heat intolerance and tremor. On examination he has a small non-tender diffuse goiter and is clinically thyrotoxic. The following results are obtained: Free T4 36 pmol/L [10-23] Free T3 12.5 pmol/L [2.8-6.8] thyroid-stimulating hormone (TSH) <0.01 mIU/L [0.3-5.0] anti-microsomal antibodies 1:1600 [<1:400] A technetium scan is as shown below. The most likely diagnosis is: A. Graves’ disease. B. toxic multinodular goiter. C. subacute thyroiditis. D. silent thyroiditis. E. Hashimoto’s thyroiditis.

RACP 2005b QUESTION 24 A patient with Paget’s disease of the pelvis has pain that is unresponsive to analgesics and non-steroidal anti-inflammatory agents. Which of the following is the most appropriate next treatment? A. Etidronate. B. Alendronate. C. Calcitonin. D. Calcitriol. E. Teriparatide.

RACP 2005 b QUESTION 33 One week after a 47-year-old male has transphenoidal pituitary surgery for a histologically confirmed non-functioning pituitary tumour, the following endocrine results are obtained: What is the next most appropriate management step at this point in time? A. Observe and repeat testing in six months. B. Commence thyroxine. C. Commence hydrocortisone. D. Commence testosterone. E. Commence growth hormone.

RACP 2005b QUESTION 43 A 72-year-old male has been in intensive care for ten days following an episode of urinary tract sepsis. He has a persistent low grade fever. He has a white cell count of 14.1 x 109/L [4.0-10.0], serum sodium is 128 mmol/L [134-145], and potassium is 5.0 mmol/L [3.5-5.0]. He has been weaned from mechanical ventilation, his renal function is normal and his delirium has cleared. His urine is sterile. His ECG demonstrates a left bundle branch block. A synthetic adrenocorticotrophic hormone (ACTH) stimulation test demonstrates baseline cortisol of 350 nmol/L which rises to 400 nmol/L at 30 minutes. He has been on noradrenaline at doses of 0.08 μg/kg/minute to 0.16 μg/kg/minute. Each attempt to cease the noradrenaline has led to hypotension associated with oliguria and obtundation. Which of the following is the most likely cause of the persistent hypotension? A. Persistent focus of infection. B. Hypovolemia. C. Adrenal suppression due to critical illness. D. Sepsis related myocardial dysfunction. E. Accumulation of opiate and sedative drugs.

RACP 2005b QUESTION 45 Which one of the following medications is most likely to result in an increase in circulating insulin concentrations? A. Metformin. B. Acarbose. C. Rosiglitazone. D. Repaglinide. E. Orlistat (Xenical).

RACP 2005b QUESTION 64 A 35-year-old woman with amenorrhoea is diagnosed with a microprolactinoma and is treated with bromocriptine 2.5 mg/day. Her prolactin level normalises, and her periods become regular. A year later she presents six weeks pregnant. What would be the most appropriate next step in management? A. Stop bromocriptine and observe. B. Continue bromocriptine and observe. C. Increase bromocriptine dosage. D. Change to cabergoline. E. Advise termination of pregnancy.

RACP 2005b QUESTION 82 A 25-year-old woman with no significant past medical history presents with weight gain, depression, easy bruising and proximal muscle weakness. On examination she has a plethoric complexion, central obesity with striae and a proximal myopathy. Investigations reveal low plasma concentrations of cortisol and adrenocorticotrophic hormone (ACTH). Which of the following is the most likely diagnosis? A. Cushing’s disease. B. Pseudo-Cushing’s syndrome. C. Factitious Cushing’s syndrome. D. Ectopic ACTH syndrome. E. Cortisol-producing adrenal adenoma.

RACP 2005b QUESTION 83 A 70-year-old man with type 2 (non-insulin-dependent) diabetes mellitus and obesity is due to have a colon cancer resection. His current medication is twice daily insulin. His exercise tolerance is good and his baseline ECG is normal. Which of the following would be the most appropriate treatment to add in order to reduce the risk of perioperative cardiac events? A. Metoprolol. B. Aspirin. C. Amiodarone. D. Magnesium. E. Nitrates.

RACP 2004a PAPER 1 QUESTION 23 The deterioration in glycaemic control over time seen in patients with type 2 (non-insulin-dependent) diabetes mellitus is primarily due to: A. medication non-compliance. B. increasing insulin resistance. C. increasing obesity. D. decreasing insulin secretion. E. reduced energy expenditure.

RACP 204a QUESTION 31 In a woman with antiphospholipid syndrome and recurrent pregnancy loss, which of the following treatment approaches provides the greatest chance of her achieving a successful pregnancy? A. Low-dose corticosteroids. B. Low-dose corticosteroids and aspirin. C. Aspirin and low molecular weight heparin. D. Intravenous immunoglobulin. E. Warfarin.

RACP 2004a The most likely cause of thyrotoxicosis producing the appearance shown in this thyroid scintiscan is: A. activating mutation of the TSH receptor. B. abnormal Gsα protein. C. thyroid-stimulating immunoglobulin. D. ret proto-oncogene mutation. E. coxsackievirus infection.

RACP 2004a QUESTION 68 A 63-year-old woman presents with weight gain, reduced energy and depression, five years after pituitary surgery and radiotherapy for a non-functioning pituitary adenoma. Current medications are thyroxine 0.15 mg/day, hydrocortisone 20 mg/day (equivalent to cortisone acetate 25 mg/day) in divided doses, conjugated oestrogen 0.625 mg/day, medroxyprogesterone 2.5 mg/day, and fluoxetine 20 mg/day. Examination is unremarkable except for truncal obesity. Her body mass index (BMI) is 30 kg/m2 [20-25] and her blood pressure is 145/85 mmHg. Which one of the following is the most likely cause of her weight gain? A. Inadequate thyroxine replacement dose. B. Excess hydrocortisone replacement dose. C. Excess oestrogen replacement dose. D. Growth hormone deficiency. E. Fluoxetine therapy.

RACP 2004b QUESTION 2 A 42-year-old man with acromegaly undergoes transphenoidal pituitary surgery for a growth hormone-secreting macroadenoma. Six months post-operatively he has an elevated insulin-like growth factor type I (IGF-I) concentration. A repeat magnetic resonance imaging (MRI) scan reveals a residual and inoperable tumour confined to the right cavernous sinus only. Which of the following is the most appropriate management? A. Expectant management. B. Radiotherapy. C. Bromocriptine. D. Octreotide. E. Cabergoline.

RACP 2004b QUESTION 32 An 18-year-old woman with type 1 (insulin-dependent) diabetes mellitus is at most risk of developing which of the following conditions? A. Addison’s disease. B. Pernicious anaemia. C. Hashimoto’s thyroiditis. D. Primary ovarian failure. E. Systemic lupus erythematosus (SLE)

RACP 2004b QUESTION 52 A 35-year-old man presents with bilateral gynaecomastia. He has a past history of viral orchitis. He has hypertension treated with spironolactone and admits to binge drinking of alcohol. Examination reveals normal body hair distribution and 20 mL testicles bilaterally. He has moderate bilateral gynaecomastia. Which of the following is the most important next step in management of his gynaecomastia? A. Cease alcohol intake. B. Magnetic resonance imaging (MRI) scan of pituitary gland. C. Testicular ultrasound. D. Karyotype analysis. E. Cease treatment with spironolactone.

RACP 2004b QUESTION 85 A 30-year-old woman presents with a 4 cm solitary thyroid nodule. Which of the following is the most appropriate initial investigation? A. Serum thyroid-stimulating hormone (TSH). B. Fine needle aspiration biopsy. C. Thyroid ultrasound. D. Technetium scan. E. Serum calcitonin.

RACP 2004b QUESTION 96 A 32-year-old woman is found to have high blood pressure (180/105 mmHg) at an insurance medical examination. She is asymptomatic. Clinical examination is normal. Similar blood pressure readings are recorded on two follow-up examinations. Serum biochemistry shows: sodium 146 mmol/L [134-146] potassium 2.5 mmol/L [3.4-5.0] creatinine 0.08 mmol/L [0.06-0.12] Which of the following investigations is the most appropriate next step? A. 24-hour urinary electrolytes. B. Upright plasma aldosterone to renin ratio. C. Captopril renogram. D. Adrenal computed tomography (CT) scanning. E. 24-hour urinary aldosterone.

RACP 2003a QUESTION 5 The insulin analogue lispro (Humalog) has a more immediate onset of action than regular human insulin. This is because lispro: A. is a smaller sized molecule. B. is more lipophilic. C. does not form hexamers subcutaneously. D. has greater affinity for the insulin receptor. E. is less protein-bound.

RACP 2003a QUESTION 37 Which one of the following anthropometric measures best correlates with the amount of visceral adipose tissue? A. Waist-to-hip ratio. B. Waist circumference. C. Body mass index. D. Skin fold thickness. E. Total body weight

RACP 2003a QUESTION 39 A healthy 85-year-old woman who is slightly below ideal body weight has a postprandial blood glucose level of 10.0 mmol/L [3.6-6.6]. Which one of the following is most likely to be responsible for the blood glucose result? A. Increased subcutaneous body fat. B. Decreased circulating insulin levels. C. Increased rate of glucose absorption. D. Decreased insulin sensitivity. E. Increased circulating growth hormone.

RACP 2003a QUESTION 41 A 63-year-old woman presents with weight gain, reduced energy and depression, five years after pituitary surgery and radiotherapy for a non-functioning pituitary adenoma. Current medications are thyroxine 0.15 mg/day, hydrocortisone 20 mg/day (equivalent to cortisone acetate 25 mg/day) in divided doses, conjugated oestrogen 0.625 mg/day, medroxyprogesterone 2.5 mg/day, and fluoxetine 20 mg/day. Examination is unremarkable except for truncal obesity. Her body mass index (BMI) is 30 kg/m2 [20-25] and her blood pressure is 145/85 mmHg. Which one of the following is the most likely cause of her weight gain? A. Inadequate thyroxine replacement dose. B. Excess hydrocortisone replacement dose. C. Excess oestrogen replacement dose. D. Growth hormone deficiency. E. Fluoxetine therapy.

RACP 2003a QUESTION 50 Which one of the following hormones shows the most consistent decline in blood levels (in both sexes) with ageing? A. Cortisol. B. Adrenocorticotrophic hormone (ACTH). C. Thyrotropin. D. Dehydroepiandrosterone (DHEA). E. Insulin.

RACP 2003b QUESTION 6 Which one of the following events is least likely to occur in a person with diet-controlled type 2 (non-insulin- dependent) diabetes mellitus who is commenced on a thiazolidinedione (e.g. pioglitazone) as a sole agent? A. Increased body fat. B. Lowering of glycosylated haemoglobin (HbA1c). C. Hypoglycaemia. D. Increased high-density lipoprotein (HDL) concentration. E. Peripheral oedema.

RACP 2003b QUESTION 19 Which one of the following would be a relative contraindication to the use of raloxifene (a selective oestrogen receptor modulator) in a perimenopausal woman? A. Severe hot flushes. B. Hypertension. C. Family history of breast cancer. D. Hypercholesterolaemia. E. Osteoporosis.

RACP 2003b QUESTION 34 A 30-year-old woman with longstanding type 1 (insulin-dependent) diabetes mellitus presents with severe hypoglycaemia. She is known to have autonomic neuropathy resulting in gastroparesis. She is on a gluten- free diet for coeliac disease and thyroxine for hypothyroidism. Clinical examination is unremarkable apart from the presence of lipohypertrophy. Which one of the following features of her history or examination most significantly increases the risk of a further severe hypoglycaemic episode in the next 24 hours? A. Thyroxine therapy. B. Gastroparesis. C. Lipohypertrophy. D. Coeliac disease. E. The current hypoglycaemic episode.

RACP 2003b QUESTION 63 Which one of the following medications is most likely to result in an increase in circulating insulin concentrations? A. Metformin. B. Acarbose. C. Rosiglitazone. D. Repaglinide. E. Orlistat (Xenical).

RACP 2003b QUESTION 86 Unawareness of hypoglycaemia is predominantly due to failure of secretion of which one of the following hormones? A. Glucagon. B. Adrenaline. C. Cortisol. D. Growth hormone. E. Somatostatin.