GEM1 Module 6 Questions

A 56-year-old man presents for a routine check-up. He is asymptomatic but has a BMI of 32 kg/m² and a family history of type 2 diabetes. Blood tests show: Fasting plasma glucose: 7.2 mmol/L (normal <5.5), HbA1c: 49 mmol/mol (6.6%). What is the most appropriate next step in management?

• Repeat fasting glucose in 6 months
• Start metformin and lifestyle advice
• Initiate insulin therapy
• Diagnose impaired fasting glucose and advise lifestyle changes
• Perform an oral glucose tolerance test

Answer explanation

The HbA1c ≥48 mmol/mol (6.5%) is diagnostic of diabetes. Asymptomatic patients with T2DM and risk factors (obesity, family history) benefit from starting metformin alongside lifestyle modification as first-line therapy. Insulin is reserved for later stages.

A 68-year-old woman with a 12-year history of T2DM presents with visual disturbances. Fundoscopy reveals microaneurysms, dot-blot hemorrhages, and hard exudates in the retina. Her latest HbA1c is 74 mmol/mol. She takes metformin and gliclazide. What is the most likely diagnosis?

• Hypertensive retinopathy
• Non-proliferative diabetic retinopathy
• Proliferative diabetic retinopathy
• Age-related macular degeneration
• Central retinal vein occlusion

Answer explanation

Dot-blot hemorrhages, microaneurysms, and hard exudates are classic signs of non-proliferative diabetic retinopathy. Proliferative retinopathy includes neovascularization, which is not described here.

A 39-year-old woman presents with weight gain, facial puffiness, and easy bruising. Examination shows a round face, central obesity, purple abdominal striae, and proximal muscle weakness. Blood pressure is 160/98 mmHg. Labs: Serum cortisol (8 AM): Elevated, ACTH: Elevated, Low-dose dexamethasone suppression test: No suppression of cortisol. What is the most likely cause?

• Adrenal adenoma
• Ectopic ACTH secretion
• Pituitary adenoma (Cushing’s disease)
• Iatrogenic steroid use
• Adrenal carcinoma

Answer explanation

In Cushing’s disease, a pituitary adenoma causes elevated ACTH and cortisol. No suppression with low-dose dexamethasone, but ACTH is high (ruling out adrenal causes). Ectopic ACTH is possible but less likely in a stable outpatient with classical signs.

A 44-year-old man is diagnosed with Cushing’s disease. MRI reveals a 3 mm pituitary adenoma. What is the most appropriate initial treatment?

• Transsphenoidal surgical resection
• Ketoconazole therapy
• Pituitary radiotherapy
• Bilateral adrenalectomy
• Observation and repeat imaging in 6 months

Answer explanation

Surgical resection via a transsphenoidal approach is the first-line treatment for confirmed Cushing’s disease. Ketoconazole is used if surgery is contraindicated or unsuccessful. Adrenalectomy is a last resort.

A 28-year-old woman presents with weight loss, anxiety, and heat intolerance. Examination reveals a smooth diffuse goitre and bilateral proptosis. Her TSH is suppressed and free T4 is elevated. Which feature most supports a diagnosis of Graves’ disease?

• Heat intolerance
• Diffuse goitre
• Exophthalmos
• Tremor
• Weight loss

Answer explanation

Exophthalmos (proptosis) is specific to Graves’ disease, due to autoimmune activation of orbital fibroblasts. Other symptoms can occur in any hyperthyroid state.

A 35-year-old woman with newly diagnosed Graves’ disease is considering treatment options. She plans to conceive within the next year. What is the most appropriate initial treatment?

• Carbimazole for 18 months
• Radioiodine therapy
• Total thyroidectomy
• Propranolol monotherapy
• Observation only

Answer explanation

Anti-thyroid drugs (like carbimazole or propylthiouracil) are first-line, especially for women planning pregnancy. Radioiodine is contraindicated in pregnancy/planning. Surgery is reserved for specific indications (e.g. large goitre, relapse, intolerance to medication).

A 30-year-old male bodybuilder presents with acne, testicular atrophy, and aggressive behaviour. He denies drug use but admits to using supplements from a gym. What is the most likely biochemical finding?

• High LH and high testosterone
• Low LH and high testosterone
• High LH and low testosterone
• Low LH and low testosterone
• Normal LH and testosterone

Answer explanation

Exogenous anabolic steroid use leads to negative feedback on the hypothalamic-pituitary axis, suppressing LH/FSH, while circulating testosterone remains high (due to injections). Testicular atrophy results from low endogenous production.

A 32-year-old male presents with fatigue and hypotension. He had been using anabolic steroids for bodybuilding but stopped abruptly 2 weeks ago. Blood tests show: Sodium 130 mmol/L, Potassium 5.6 mmol/L, Cortisol low, ACTH low. What is the most likely diagnosis?

• Primary adrenal insufficiency (Addison’s disease)
• Secondary adrenal insufficiency
• Congenital adrenal hyperplasia
• Acute adrenal crisis
• Cushing’s syndrome

Answer explanation

Chronic anabolic steroid use suppresses ACTH production via feedback inhibition. Sudden withdrawal leads to secondary adrenal insufficiency, characterised by low ACTH and low cortisol. Electrolyte imbalance may be present but is less severe than in Addison’s disease.

A 72-year-old man presents to A&E with a rapidly expanding neck swelling and respiratory distress after a central venous catheter insertion attempt. The swelling is located in the anterior triangle of the neck. Which of the following structures was most likely injured during the procedure?

• Spinal accessory nerve
• Subclavian vein
• Internal jugular vein
• External carotid artery
• Brachial plexus

Answer explanation

The internal jugular vein, along with the common carotid artery and vagus nerve, lies within the carotid sheath in the anterior triangle of the neck. It is a common site for central line insertion. Injury can lead to hematoma and airway compromise. The spinal accessory nerve and brachial plexus are found in the posterior triangle, not relevant here.

A 45-year-old woman presents with a painless lump in the left upper neck (level II lymph node) and a hoarse voice lasting several weeks. Which of the following is the most likely primary site of a malignancy causing this lymph node enlargement?

• Thyroid gland
• Larynx (voice box)
• Nasopharynx (upper throat behind the nose)
• Tongue (front part)
• Salivary gland (parotid)

Answer explanation

Level II cervical lymph nodes drain the larynx, particularly the supraglottic and glottic regions. Hoarseness suggests involvement of the vocal cords (larynx). Laryngeal cancers commonly metastasize to level II nodes. Nasopharyngeal cancers usually present with level II nodes but often have nasal symptoms.