Endocrinology & Diabetes — MCQs
On this page
A 68-year-old woman with type 2 diabetes for 12 years presents with a 6-month history of progressive numbness and burning pain in both feet, worse at night. Examination reveals reduced pin-prick sensation to mid-calf bilaterally and absent ankle reflexes. Vibration sense is reduced. Monofilament testing shows reduced sensation at multiple plantar sites. What is the most appropriate explanation for these findings?
A 44-year-old woman undergoes thyroid function tests as part of an investigation for fatigue. Results show TSH 0.05 mU/L (0.5-5.0), free T4 28 pmol/L (10-22), and free T3 8.2 pmol/L (3.5-6.5). What is the most appropriate classification of her thyroid status?
A 52-year-old man with newly diagnosed type 2 diabetes attends for dietary advice. His BMI is 32 kg/m², HbA1c is 58 mmol/mol, and he takes no other medications. He asks about alcohol consumption. What is the most appropriate advice regarding alcohol intake for patients with diabetes?
Which of the following is the correct target HbA1c for an adult with type 2 diabetes managed on lifestyle and metformin alone, according to NICE guidelines?
A 31-year-old woman with type 1 diabetes attends the emergency department with nausea and vomiting. She is 26 weeks pregnant. Blood tests show: glucose 14.2 mmol/L, pH 7.26, bicarbonate 13 mmol/L, ketones 3.4 mmol/L. She is alert and oriented. According to current UK guidance for managing DKA in pregnancy, which of the following insulin infusion rates and glucose thresholds is most appropriate?
Which of the following patients with newly diagnosed type 2 diabetes should be commenced on dual therapy with metformin and an SGLT2 inhibitor at diagnosis, according to NICE guidelines?
A 56-year-old woman with type 2 diabetes presents for review. Her current medications include metformin 1g twice daily, empagliflozin 25mg once daily, and dulaglutide 1.5mg once weekly. Her HbA1c is 54 mmol/mol (7.1%), BMI is 29 kg/m², and blood pressure is 138/82 mmHg. Urine albumin:creatinine ratio is 4.2 mg/mmol (normal <3) confirmed on two occasions. eGFR is 68 mL/min/1.73m². She has no retinopathy and no history of cardiovascular disease. Which of the following additional medications would provide the greatest benefit in reducing her risk of progressive chronic kidney disease?
What is the diagnostic criterion for diabetic ketoacidosis according to current UK guidelines?
A 67-year-old man with type 2 diabetes for 20 years presents to his GP with a painless ulcer on the sole of his right foot that he noticed 2 weeks ago. He has reduced sensation in both feet to monofilament testing. The ulcer is 2 cm in diameter, located over the first metatarsal head, with granulation tissue at the base but no purulent discharge. His foot pulses are palpable and capillary refill time is 2 seconds. There is no cellulitis or systemic features of infection. An X-ray of the foot shows no evidence of osteomyelitis. Which of the following is the most important immediate management?
A 42-year-old man presents with a 2-day history of fever, malaise, and severe neck pain radiating to his jaw. He had an upper respiratory tract infection 3 weeks ago. On examination, his temperature is 38.4°C and his thyroid gland is enlarged, firm, and exquisitely tender. Blood tests show: TSH <0.01 mU/L, free T4 34 pmol/L, ESR 72 mm/hr, CRP 86 mg/L. Which of the following investigation findings would most strongly support the likely diagnosis?
Endocrinology & Diabetes UK Medical PG Practice Questions and MCQs
Question 101: A 68-year-old woman with type 2 diabetes for 12 years presents with a 6-month history of progressive numbness and burning pain in both feet, worse at night. Examination reveals reduced pin-prick sensation to mid-calf bilaterally and absent ankle reflexes. Vibration sense is reduced. Monofilament testing shows reduced sensation at multiple plantar sites. What is the most appropriate explanation for these findings?
- A. These findings represent early diabetic neuropathy affecting only small nerve fibres
- B. The sensory loss pattern indicates peripheral vascular disease rather than neuropathy
- C. The clinical presentation demonstrates mixed small and large fibre diabetic neuropathy (Correct Answer)
- D. Absent ankle reflexes alone confirm the diagnosis without need for further assessment
- E. The symptoms are likely due to vitamin B12 deficiency from metformin therapy
Explanation: ***The clinical presentation demonstrates mixed small and large fibre diabetic neuropathy*** - This patient exhibits **small fibre** involvement (numbness, burning pain, and reduced pin-prick sensation) and **large fibre** involvement (reduced vibration sense and absent ankle reflexes). - The progressive, symmetric, "stocking" distribution of sensory loss in a long-term diabetic patient is the classic hallmark of **Distal Symmetric Polyneuropathy (DSPN)**.*These findings represent early diabetic neuropathy affecting only small nerve fibres* - Small fibre neuropathy primarily causes **pain and temperature deficits** but does not typically cause the **loss of vibration sense** or **absent ankle reflexes** seen here. - The involvement of **monofilament testing** and reduced vibration indicates that large myelinated fibres are also significantly compromised.*The sensory loss pattern indicates peripheral vascular disease rather than neuropathy* - Peripheral vascular disease (PVD) typically presents with **intermittent claudication**, absent pulses, or skin changes like pallor and coolness, which are not described. - The "stocking" sensory deficit and purely **neurological exam findings** (reflexes and sensation) point directly to a neuropathic rather than ischemic origin.*Absent ankle reflexes alone confirm the diagnosis without need for further assessment* - While **absent ankle reflexes** are a common finding in diabetic neuropathy, they can also occur with normal aging or other lumbosacral pathologies. - A clinical diagnosis requires a constellation of findings, including **sensory testing** (pin-prick, vibration, monofilament) and a consistent history, not just one isolated sign.*The symptoms are likely due to vitamin B12 deficiency from metformin therapy* - While metformin can cause **Vitamin B12 deficiency**, which leads to neuropathy, the patient's 12-year history of diabetes makes **hyperglycemia-induced nerve damage** a more statistically likely cause. - B12 deficiency neuropathy often involves prominent **proprioception loss** and can be associated with megaloblastic anemia, which is not suggested by the findings.
Question 102: A 44-year-old woman undergoes thyroid function tests as part of an investigation for fatigue. Results show TSH 0.05 mU/L (0.5-5.0), free T4 28 pmol/L (10-22), and free T3 8.2 pmol/L (3.5-6.5). What is the most appropriate classification of her thyroid status?
- A. Subclinical hypothyroidism
- B. Primary hypothyroidism
- C. Subclinical hyperthyroidism
- D. Overt hyperthyroidism (Correct Answer)
- E. Secondary hypothyroidism
Explanation: ***Overt hyperthyroidism*** - The patient's thyroid function tests show a **suppressed TSH** (0.05 mU/L, below the normal range) and **elevated free T4** (28 pmol/L, above normal) and **elevated free T3** (8.2 pmol/L, above normal). - This combination of low TSH with high free T4 and free T3 is the hallmark diagnostic criteria for **overt primary hyperthyroidism**. *Subclinical hypothyroidism* - This condition is characterized by an **elevated TSH** (above the reference range) with **normal free T4** and **normal free T3** levels. - The patient's TSH is low, and her free T4 and T3 are elevated, which contradicts the definition of subclinical hypothyroidism. *Primary hypothyroidism* - Typically presents with a **high TSH** and a **low free T4** (and often low free T3), indicating primary thyroid gland failure. - The patient's results show a low TSH and high free T4/T3, which is the exact opposite biochemical picture of primary hypothyroidism. *Subclinical hyperthyroidism* - This is defined by a **low or suppressed TSH** in the presence of **normal free T4** and **normal free T3** levels. - Although the TSH is suppressed, the **free T4 and free T3 levels are elevated**, which means the condition has progressed beyond subclinical to overt hyperthyroidism. *Secondary hypothyroidism* - This condition occurs due to **pituitary or hypothalamic dysfunction**, leading to an **inappropriately normal or low TSH** in conjunction with a **low free T4**. - While the patient has a low TSH, her free T4 and free T3 levels are high, indicating an excess of thyroid hormones, not a deficiency as seen in hypothyroidism.
Question 103: A 52-year-old man with newly diagnosed type 2 diabetes attends for dietary advice. His BMI is 32 kg/m², HbA1c is 58 mmol/mol, and he takes no other medications. He asks about alcohol consumption. What is the most appropriate advice regarding alcohol intake for patients with diabetes?
- A. Complete abstinence from alcohol is recommended for all patients with diabetes
- B. Limit intake to no more than 14 units per week spread over at least 3 days (Correct Answer)
- C. Alcohol consumption should be limited to no more than 21 units per week for men
- D. Occasional binge drinking is acceptable as long as weekly totals remain low
- E. Alcohol intake has no effect on blood glucose control and requires no special advice
Explanation: ***Limit intake to no more than 14 units per week spread over at least 3 days***- Current **UK clinical guidelines** state that patients with diabetes should follow the same alcohol limits as the general population, which is **14 units per week** for both men and women.- It is advised to spread consumption over **three or more days** to avoid the risks associated with heavy drinking episodes and to maintain better metabolic control.*Complete abstinence from alcohol is recommended for all patients with diabetes*- **Complete abstinence** is not medically required for diabetes management unless the patient has specific complications like **severe hypertriglyceridemia** or **pancreatitis**.- Moderate consumption is generally safe provided the patient is aware of the **caloric content** and potential for delayed **hypoglycemia**.*Alcohol consumption should be limited to no more than 21 units per week for men*- The limit of **21 units for men** is based on outdated guidelines; current recommendations have been lowered to align with the **14-unit limit** for everyone.- Consuming 21 units increases the risk of **weight gain** (due to empty calories) and potentially worsening **HbA1c levels**.*Occasional binge drinking is acceptable as long as weekly totals remain low*- **Binge drinking** should be strictly avoided as it significantly increases the risk of **severe hypoglycemia** by inhibiting **gluconeogenesis** in the liver.- It also contributes to higher **blood pressure** and increased cardiovascular risk, which is already a concern in patients with **Type 2 Diabetes**.*Alcohol intake has no effect on blood glucose control and requires no special advice*- Alcohol can significantly affect **glycemic control**; it can cause hypoglycemia in those on insulin/secretagogues or contribute to **hyperglycemia** if mixed with sugary drinks.- Large amounts of alcohol contribute to **weight gain** and **insulin resistance**, making it an essential topic for dietary education in **newly diagnosed** patients.
Question 104: Which of the following is the correct target HbA1c for an adult with type 2 diabetes managed on lifestyle and metformin alone, according to NICE guidelines?
- A. 53 mmol/mol (7.0%)
- B. 58 mmol/mol (7.5%)
- C. 64 mmol/mol (8.0%)
- D. 48 mmol/mol (6.5%) (Correct Answer)
- E. 75 mmol/mol (9.0%)
Explanation: ***48 mmol/mol (6.5%)*** - According to **NICE guidelines**, the target HbA1c for patients managed by **lifestyle modifications alone** or by **lifestyle plus a single drug** not associated with hypoglycemia (like **metformin**) is 48 mmol/mol. - This aggressive target is set because **metformin** has a low risk of causing **hypoglycemia**, allowing for tighter glycemic control to prevent **microvascular complications**. *53 mmol/mol (7.0%)* - This is the target HbA1c level recommended when a patient is prescribed a drug associated with **hypoglycemia**, such as a **sulfonylurea** or **insulin**. - It is also the threshold at which **treatment intensification** (adding a second drug) should be considered if the HbA1c rises to this level or above. *58 mmol/mol (7.5%)* - This value is not a standard target for an otherwise healthy adult on metformin but may be considered as an **individualized target** for specific clinical scenarios. - It represents a level where **glycemic control** is suboptimal for most young or fit patients, needing a review of medication adherence or lifestyle. *64 mmol/mol (8.0%)* - This higher target is generally reserved for patients with **significant frailty**, limited **life expectancy**, or those where the risks of intensive treatment outweigh the benefits. - Targets are often relaxed to this level in the **elderly** to prevent falls or other adverse events resulting from tight control. *75 mmol/mol (9.0%)* - An HbA1c of 75 mmol/mol indicates poor metabolic control and is well above the recommended **therapeutic range** for any standard NICE guideline category. - Patients at this level are at a significantly increased risk of developing **long-term complications** such as neuropathy, retinopathy, and nephropathy.
Question 105: A 31-year-old woman with type 1 diabetes attends the emergency department with nausea and vomiting. She is 26 weeks pregnant. Blood tests show: glucose 14.2 mmol/L, pH 7.26, bicarbonate 13 mmol/L, ketones 3.4 mmol/L. She is alert and oriented. According to current UK guidance for managing DKA in pregnancy, which of the following insulin infusion rates and glucose thresholds is most appropriate?
- A. Fixed rate intravenous insulin at 0.1 units/kg/hour; add 10% dextrose when glucose <14 mmol/L (Correct Answer)
- B. Fixed rate intravenous insulin at 0.05 units/kg/hour; add 10% dextrose when glucose <10 mmol/L
- C. Fixed rate intravenous insulin at 0.1 units/kg/hour; add 10% dextrose when glucose <10 mmol/L
- D. Variable rate intravenous insulin guided by hourly blood glucose; add 5% dextrose when glucose <14 mmol/L
- E. Fixed rate intravenous insulin at 0.05 units/kg/hour; add 10% dextrose when glucose <14 mmol/L
Explanation: ***Fixed rate intravenous insulin at 0.1 units/kg/hour; add 10% dextrose when glucose <14 mmol/L*** - In pregnancy, **Diabetic Ketoacidosis (DKA)** often occurs at lower blood glucose levels; thus, **10% dextrose** is initiated early (when glucose is <14 mmol/L) to allow the **Fixed Rate Intravenous Insulin Infusion (FRIII)** to continue clearing ketones without causing hypoglycemia. - The standard weight-based dose for FRIII is **0.1 units/kg/hour** (using pre-pregnancy or booking weight) to effectively suppress ketogenesis and treat the metabolic acidosis. *Fixed rate intravenous insulin at 0.05 units/kg/hour; add 10% dextrose when glucose <10 mmol/L* - An insulin rate of **0.05 units/kg/hour** is insufficient for the initial management of DKA, as it may not provide enough insulin to shut down **ketone production**. - A glucose threshold of **10 mmol/L** is used for non-pregnant adults, but is too low for pregnant patients who carry a higher risk of **euglycemic DKA** and fetal distress. *Fixed rate intravenous insulin at 0.1 units/kg/hour; add 10% dextrose when glucose <10 mmol/L* - While the insulin rate of **0.1 units/kg/hour** is correct, the glucose threshold for adding dextrose is inappropriate for the physiological state of pregnancy. - Waiting until glucose is **<10 mmol/L** increases the risk of maternal hypoglycemia and potential **fetal compromise** due to reduced placental glucose transfer. *Variable rate intravenous insulin guided by hourly blood glucose; add 5% dextrose when glucose <14 mmol/L* - **Variable Rate Intravenous Insulin Infusion (VRIII)** is not the gold standard for acute DKA management; **Fixed Rate (FRIII)** is required to suppress lipolysis and resolve ketosis. - **10% dextrose** is preferred over 5% dextrose in pregnancy to provide a more concentrated calorie source to maintain maternal glucose levels while insulin continues. *Fixed rate intravenous insulin at 0.05 units/kg/hour; add 10% dextrose when glucose <14 mmol/L* - Although the dextrose threshold matches pregnancy guidelines, the **0.05 units/kg/hour** insulin dose is half of the recommended starting rate. - Inadequate insulin dosing delays the resolution of **acidemia** and **ketonaemia**, which is dangerous for both the mother and the fetus.
Question 106: Which of the following patients with newly diagnosed type 2 diabetes should be commenced on dual therapy with metformin and an SGLT2 inhibitor at diagnosis, according to NICE guidelines?
- A. A 58-year-old man with HbA1c 62 mmol/mol, BMI 32 kg/m², and no complications
- B. A 52-year-old woman with HbA1c 68 mmol/mol, previous myocardial infarction 2 years ago, and eGFR 72 mL/min/1.73m² (Correct Answer)
- C. A 65-year-old man with HbA1c 58 mmol/mol, BMI 28 kg/m², and chronic kidney disease stage 3a
- D. A 70-year-old man with HbA1c 64 mmol/mol, heart failure with reduced ejection fraction, and eGFR 38 mL/min/1.73m²
- E. A 48-year-old woman with HbA1c 74 mmol/mol, BMI 35 kg/m², and no established cardiovascular disease
Explanation: ***A 52-year-old woman with HbA1c 68 mmol/mol, previous myocardial infarction 2 years ago, and eGFR 72 mL/min/1.73m²***- According to **NICE guidelines (NG28)**, patients with **established atherosclerotic cardiovascular disease (ASCVD)**, such as a previous myocardial infarction, should be offered dual therapy with **Metformin and an SGLT2 inhibitor** at diagnosis.- The patient's **eGFR 72 mL/min/1.73m²** allows for safe initiation of an SGLT2 inhibitor, providing significant **cardiovascular protection** and improving glycemic control.*A 58-year-old man with HbA1c 62 mmol/mol, BMI 32 kg/m², and no complications*- In the absence of established cardiovascular disease, **heart failure**, or **chronic kidney disease**, **Metformin monotherapy** remains the first-line treatment for newly diagnosed type 2 diabetes.- Dual therapy at diagnosis is reserved for specific high-risk conditions, which are not present in this patient.*A 65-year-old man with HbA1c 58 mmol/mol, BMI 28 kg/m², and chronic kidney disease stage 3a*- While SGLT2 inhibitors are beneficial for **chronic kidney disease (CKD)**, the primary NICE recommendation for immediate dual therapy at diagnosis emphasizes those with **established ASCVD** or **heart failure**.- For a patient with **CKD stage 3a (eGFR 45-59)** and a relatively lower HbA1c, initial management typically involves **Metformin** (if eGFR >30 and stable), with an SGLT2i considered as an add-on later.*A 70-year-old man with HbA1c 64 mmol/mol, heart failure with reduced ejection fraction, and eGFR 38 mL/min/1.73m²*- Although SGLT2 inhibitors are indicated for **heart failure with reduced ejection fraction (HFrEF)**, an **eGFR of 38 mL/min/1.73m²** (CKD stage 3b) is often below the initiation threshold for some SGLT2 inhibitors for *glycemic* purposes (typically eGFR >45 mL/min/1.73m²).- While SGLT2 inhibitors can be *continued* and sometimes *initiated* at lower eGFRs for heart failure/CKD benefits irrespective of glycemic control, the woman with previous MI and good eGFR is a clearer candidate for *initial* dual therapy for standard glycemic and CV benefits.*A 48-year-old woman with HbA1c 74 mmol/mol, BMI 35 kg/m², and no established cardiovascular disease*- Despite a high **HbA1c of 74 mmol/mol** and **obesity**, the absence of established **atherosclerotic cardiovascular disease**, **heart failure**, or **CKD** means initial dual therapy with an SGLT2 inhibitor is not mandated by NICE guidelines at diagnosis.- This patient would typically start on **Metformin monotherapy**, with escalation to dual or triple therapy (potentially including an SGLT2i or GLP-1 RA for weight/glycemic control) if glycemic targets are not met.
Question 107: A 56-year-old woman with type 2 diabetes presents for review. Her current medications include metformin 1g twice daily, empagliflozin 25mg once daily, and dulaglutide 1.5mg once weekly. Her HbA1c is 54 mmol/mol (7.1%), BMI is 29 kg/m², and blood pressure is 138/82 mmHg. Urine albumin:creatinine ratio is 4.2 mg/mmol (normal <3) confirmed on two occasions. eGFR is 68 mL/min/1.73m². She has no retinopathy and no history of cardiovascular disease. Which of the following additional medications would provide the greatest benefit in reducing her risk of progressive chronic kidney disease?
- A. Amlodipine 5mg once daily
- B. Ramipril 5mg once daily (Correct Answer)
- C. Aspirin 75mg once daily
- D. Atorvastatin 20mg once daily
- E. Dapagliflozin 10mg once daily
Explanation: ***Ramipril 5mg once daily*** - In patients with **Type 2 diabetes** and **microalbuminuria** (ACR > 3 mg/mmol), an **ACE inhibitor** or ARB is the first-line treatment for **renoprotection**, regardless of baseline blood pressure. - Ramipril reduces intraglomerular pressure and provides specific **anti-proteinuric effects** that slow the progression to end-stage renal disease. *Amlodipine 5mg once daily* - While effective for **hypertension**, calcium channel blockers like amlodipine lack the specific **renoprotective mechanisms** offered by blockade of the renin-angiotensin system. - It is generally used as a second or third-line agent if blood pressure remains elevated after maximizing **ACE inhibitor** therapy. *Aspirin 75mg once daily* - Aspirin is indicated for **secondary prevention** in patients with established cardiovascular disease, but this patient has no current history of such events. - It does not have a direct role in slowing the progression of **diabetic nephropathy** or reducing albuminuria. *Atorvastatin 20mg once daily* - Statins are critical for reducing overall **cardiovascular risk** in diabetic patients, especially those with renal impairment. - However, they do not provide the same targeted benefit in reducing **albuminuria** or delaying the worsening of **CKD** as ACE inhibitors do. *Dapagliflozin 10mg once daily* - This patient is already taking **empagliflozin**, and there is no clinical benefit or indication for combining two different **SGLT2 inhibitors**. - SGLT2 inhibitors do provide renoprotection, but this benefit is already being utilized through her current prescription.
Question 108: What is the diagnostic criterion for diabetic ketoacidosis according to current UK guidelines?
- A. Blood glucose >11 mmol/L, pH <7.35, bicarbonate <15 mmol/L, ketonaemia >3 mmol/L
- B. Blood glucose >11 mmol/L, pH <7.3, bicarbonate <15 mmol/L, ketonaemia >3 mmol/L (Correct Answer)
- C. Blood glucose >13.9 mmol/L, pH <7.3, bicarbonate <18 mmol/L, ketonuria 2+ or more
- D. Blood glucose >11 mmol/L, pH <7.35, bicarbonate <18 mmol/L, ketonaemia >5 mmol/L
- E. Blood glucose >13.9 mmol/L, pH <7.2, bicarbonate <15 mmol/L, ketonaemia >3 mmol/L
Explanation: ***Blood glucose >11 mmol/L, pH <7.3, bicarbonate <15 mmol/L, ketonaemia >3 mmol/L*** - According to **JBDS guidelines**, the diagnostic triad of DKA requires **ketonaemia (>3 mmol/L)**, **hyperglycaemia (>11 mmol/L)** or known diabetes, and **acidosis (pH <7.3 or bicarbonate <15 mmol/L)**. - This combination confirms the presence of systemic ketosis and metabolic acidosis necessary for a DKA diagnosis in the UK. *Blood glucose >11 mmol/L, pH <7.35, bicarbonate <15 mmol/L, ketonaemia >3 mmol/L* - This option uses a **pH threshold of <7.35**, which is the general limit for normal physiological pH but too high for the specific diagnosis of DKA. - In DKA, the **acidosis must be more severe (pH <7.3)** to meet the standard diagnostic criteria. *Blood glucose >13.9 mmol/L, pH <7.3, bicarbonate <18 mmol/L, ketonuria 2+ or more* - A **bicarbonate <18 mmol/L** and **glucose >13.9 mmol/L** align more closely with older **American Diabetes Association (ADA)** guidelines rather than current UK practice. - While **ketonuria 2+** is acceptable if blood ketones cannot be measured, the primary diagnostic thresholds for glucose and bicarbonate provided here are incorrect for the UK. *Blood glucose >11 mmol/L, pH <7.35, bicarbonate <18 mmol/L, ketonaemia >5 mmol/L* - **Ketonaemia >5 mmol/L** actually indicates **severe DKA** requiring senior involvement, rather than the initial entry threshold for diagnosis. - The **pH (<7.35)** and **bicarbonate (<18 mmol/L)** values are both too high to satisfy the precise UK definition of DKA. *Blood glucose >13.9 mmol/L, pH <7.2, bicarbonate <15 mmol/L, ketonaemia >3 mmol/L* - While the **pH <7.2** would certainly meet the criteria for DKA, it is a marker of **moderate severity** rather than the minimum diagnostic cut-off of **pH <7.3**. - The **glucose value (>13.9 mmol/L)** is unnecessarily high, as DKA can be diagnosed with levels as low as **11 mmol/L** or even lower in euglycaemic DKA cases.
Question 109: A 67-year-old man with type 2 diabetes for 20 years presents to his GP with a painless ulcer on the sole of his right foot that he noticed 2 weeks ago. He has reduced sensation in both feet to monofilament testing. The ulcer is 2 cm in diameter, located over the first metatarsal head, with granulation tissue at the base but no purulent discharge. His foot pulses are palpable and capillary refill time is 2 seconds. There is no cellulitis or systemic features of infection. An X-ray of the foot shows no evidence of osteomyelitis. Which of the following is the most important immediate management?
- A. Commence oral antibiotics and arrange follow-up in 2 weeks
- B. Refer to vascular surgery for consideration of revascularisation
- C. Arrange urgent debridement in the operating theatre
- D. Refer to multidisciplinary foot clinic within 24 hours (Correct Answer)
- E. Apply topical antimicrobial dressing and review in 1 week
Explanation: ***Refer to multidisciplinary foot clinic within 24 hours***- This patient presents with a **neuropathic diabetic foot ulcer**, characterized by a painless ulcer on a pressure point (first metatarsal head) and **reduced sensation** from long-standing diabetes.- According to **NICE guidelines**, any new diabetic foot ulcer requires urgent referral to a **multidisciplinary foot care service (MDFT)** within **24 hours** for specialized assessment, offloading, and wound management to prevent complications. *Commence oral antibiotics and arrange follow-up in 2 weeks*- This ulcer shows **no signs of infection** (no purulent discharge, cellulitis, or systemic features), so empirical oral antibiotics are not indicated at this stage.- A 2-week follow-up for a **diabetic foot ulcer** is too long and significantly increases the risk of rapid deterioration and severe complications without specialized care. *Refer to vascular surgery for consideration of revascularisation*- The patient has **palpable foot pulses** and a normal **capillary refill time** of 2 seconds, indicating adequate peripheral arterial perfusion.- The primary etiology here is **neuropathy**, not significant peripheral arterial disease, making urgent vascular surgical referral unnecessary. *Arrange urgent debridement in the operating theatre*- The ulcer base shows healthy **granulation tissue** and there is no evidence of extensive necrosis, deep infection, or gas gangrene requiring urgent operating theatre debridement.- Minor debridement may be necessary and can be performed by a **podiatrist** within the specialized foot clinic setting, not necessarily requiring an operating theatre. *Apply topical antimicrobial dressing and review in 1 week*- Managing a **diabetic neuropathic ulcer** solely with topical antimicrobial dressings in primary care is insufficient given the patient's **loss of protective sensation** and high risk of complications.- **Topical antimicrobials** are not recommended for clean, granulating ulcers without signs of infection and do not address the critical need for pressure relief and specialist care.
Question 110: A 42-year-old man presents with a 2-day history of fever, malaise, and severe neck pain radiating to his jaw. He had an upper respiratory tract infection 3 weeks ago. On examination, his temperature is 38.4°C and his thyroid gland is enlarged, firm, and exquisitely tender. Blood tests show: TSH <0.01 mU/L, free T4 34 pmol/L, ESR 72 mm/hr, CRP 86 mg/L. Which of the following investigation findings would most strongly support the likely diagnosis?
- A. Positive TSH receptor antibodies
- B. Raised radioiodine uptake on thyroid scintigraphy
- C. Multiple thyroid nodules on ultrasound
- D. Low radioiodine uptake on thyroid scintigraphy (Correct Answer)
- E. Positive anti-thyroid peroxidase antibodies
Explanation: ***Low radioiodine uptake on thyroid scintigraphy***- A **low or absent radioiodine uptake** is characteristic of **Subacute (De Quervain's) Thyroiditis**, as inflammation causes follicular cell destruction, preventing iodine trapping despite high circulating thyroid hormone levels from leakage.- This finding confirms that the thyrotoxicosis is due to **leakage of preformed hormone** rather than **excessive new hormone synthesis**, which would show high uptake.*Positive TSH receptor antibodies*- These antibodies are diagnostic for **Graves' disease**, an autoimmune condition causing hyperthyroidism, which typically presents with a painless goiter and often ophthalmopathy or pretibial myxedema.- The patient's **exquisitely tender thyroid**, recent viral infection, and significantly elevated inflammatory markers (**ESR, CRP**) are inconsistent with **Graves' disease**.*Raised radioiodine uptake on thyroid scintigraphy*- **Increased radioiodine uptake** indicates an **overactive thyroid gland** actively synthesizing excessive hormones, as seen in **Graves' disease** or **toxic multinodular goiter**.- In **Subacute Thyroiditis**, the inflamed and damaged follicular cells lose their ability to concentrate iodine, leading to *low* rather than *raised* uptake.*Multiple thyroid nodules on ultrasound*- While **multiple thyroid nodules** can be a cause of hyperthyroidism (toxic multinodular goiter), this condition typically develops slowly in older patients and does not present with acute pain, fever, or marked inflammatory markers.- Ultrasound in **De Quervain's thyroiditis** may show diffuse hypoechoic areas but **multiple distinct nodules** are not its primary diagnostic feature.*Positive anti-thyroid peroxidase antibodies*- **Anti-thyroid peroxidase (TPO) antibodies** are strongly associated with **Hashimoto's thyroiditis**, an autoimmune condition leading to hypothyroidism and typically presenting with a firm, painless goiter.- Although transiently positive in some other thyroid conditions, these antibodies are not the primary diagnostic indicator for the acute, painful, and self-limiting nature of **Subacute Thyroiditis**.
Practice by Chapter
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free