1. A 58-year-old man with newly diagnosed type 2 diabetes has an HbA1c of 74 mmol/mol. He has a history of myocardial infarction and chronic kidney disease stage 3a. He is overweight and has no contraindications to standard first-line medicines.
Which ONE of the following is the most appropriate initial medicines optimisation approach?
A. Start gliclazide alone.
B. Start insulin immediately in all cases.
C. Consider metformin and an SGLT2 inhibitor as part of initial treatment, taking account of renal function and cardiovascular risk.
D. Start pioglitazone because previous myocardial infarction is an indication.
E. Use lifestyle advice only for 12 months before starting medicines.
2. A 72-year-old woman with type 2 diabetes takes metformin, ramipril and furosemide. She develops vomiting and diarrhoea and is unable to keep fluids down. Her daughter asks whether she should continue taking metformin while acutely unwell.
Which ONE of the following is the most appropriate advice?
A. Continue metformin at double dose.
B. Stop all medicines permanently.
C. Take metformin only if blood glucose is below 4 mmol/L.
D. Replace metformin with ibuprofen.
E. Temporarily withhold metformin during significant dehydration and seek clinical advice.
3. A 64-year-old man with type 2 diabetes is taking empagliflozin. He is admitted with abdominal pain, vomiting and rapid breathing. His blood glucose is 9.8 mmol/L and blood ketones are raised.
Which ONE of the following is the most appropriate concern?
A. SGLT2 inhibitor-associated diabetic ketoacidosis can occur even when blood glucose is not markedly elevated.
B. Diabetic ketoacidosis is impossible unless blood glucose is above 30 mmol/L.
C. Empagliflozin prevents ketone formation.
D. Raised ketones are expected and need no action.
E. The symptoms are diagnostic of uncomplicated hypoglycaemia.
4. A 46-year-old man with type 1 diabetes treated with basal-bolus insulin reports repeated early morning blood glucose readings between 2.8 and 3.5 mmol/L. His pre-bedtime readings are usually 7–9 mmol/L.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Advise increasing the basal insulin dose.
B. Stop all rapid-acting insulin.
C. Reassure him that early morning hypoglycaemia is harmless.
D. Recommend review of his basal insulin regimen because nocturnal hypoglycaemia is likely.
E. Advise taking extra rapid-acting insulin at bedtime.
5. A 70-year-old woman with type 2 diabetes takes gliclazide. She reports sweating, shaking and confusion before lunch on days when she skips breakfast. Her capillary blood glucose during one episode was 2.9 mmol/L.
Which ONE of the following is the most likely explanation?
A. Metformin intolerance.
B. Sulfonylurea-associated hypoglycaemia.
C. Hyperosmolar hyperglycaemic state.
D. Diabetic ketoacidosis.
E. Thyrotoxicosis.
6. A 52-year-old woman using semaglutide for type 2 diabetes reports persistent severe upper abdominal pain radiating to her back, associated with vomiting.
Which ONE of the following is the most appropriate action?
A. Reassure her this is expected and continue treatment.
B. Increase the semaglutide dose.
C. Take loperamide and continue.
D. Skip one dose then restart without review.
E. Arrange urgent medical assessment for possible pancreatitis.
7. A 63-year-old man with type 2 diabetes and established heart failure is being considered for pioglitazone because his HbA1c remains above target.
Which ONE of the following is the most appropriate concern?
A. Pioglitazone can cause fluid retention and may worsen heart failure.
B. Pioglitazone is first-line in all patients with heart failure.
C. Pioglitazone treats acute pulmonary oedema.
D. Pioglitazone prevents all hypoglycaemia.
E. Pioglitazone has no cardiovascular cautions.
8. A 28-year-old woman with type 1 diabetes is unwell with influenza. She is eating very little and asks whether she should stop her basal insulin until she feels better.
Which ONE of the following is the most appropriate advice?
A. Stop basal insulin while not eating.
B. Take basal insulin only if glucose is below 4 mmol/L.
C. Replace basal insulin with paracetamol.
D. Continue basal insulin and follow sick-day guidance, including checking ketones if advised.
E. Omit all insulin until normal meals restart.
9. A 75-year-old man takes prednisolone 7.5 mg daily long term for polymyalgia rheumatica. He is admitted with sepsis and hypotension.
Which ONE of the following is the most appropriate endocrine-related concern?
A. Prednisolone prevents adrenal suppression.
B. He may require stress-dose corticosteroid cover due to possible adrenal suppression.
C. Long-term corticosteroids protect against infection.
D. Prednisolone should always be stopped abruptly during sepsis.
E. Corticosteroids have no relevance during acute illness.
10. A 61-year-old woman takes levothyroxine each morning. She has recently started taking calcium carbonate at breakfast. Her latest blood tests show a raised TSH, and she reports increasing tiredness.
Which ONE of the following is the most appropriate advice?
A. Stop levothyroxine permanently.
B. Take calcium carbonate at the same time to improve absorption.
C. Separate levothyroxine from calcium because calcium can reduce levothyroxine absorption.
D. Double levothyroxine without review.
E. Take levothyroxine only when symptomatic.
11. A 43-year-old woman taking carbimazole for hyperthyroidism contacts the pharmacy because she has developed a sore throat, fever and mouth ulcers.
Which ONE of the following is the most appropriate advice?
A. Continue carbimazole and review in six months.
B. Take ibuprofen and ignore the symptoms.
C. Double the carbimazole dose.
D. Stop carbimazole and seek urgent medical assessment because of possible agranulocytosis.
E. Take levothyroxine with carbimazole.
12. A 36-year-old woman presents with weight loss, heat intolerance, palpitations and tremor. Blood tests show suppressed TSH and raised free T4.
Which ONE of the following is the most likely diagnosis?
A. Hyperthyroidism.
B. Primary hypothyroidism.
C. Addison’s disease.
D. Hyperparathyroidism.
E. Type 1 diabetes.
13. A 69-year-old man taking levothyroxine has symptoms of palpitations, weight loss and tremor. His TSH is suppressed and free T4 is raised.
Which ONE of the following is the most appropriate interpretation?
A. Undertreatment of hypothyroidism.
B. Normal thyroid replacement.
C. Carbimazole-induced hypothyroidism.
D. Addisonian crisis.
E. Possible levothyroxine over-replacement requiring review.
14. A 55-year-old woman has symptoms of hypothyroidism. Blood tests show raised TSH and low free T4.
Which ONE of the following is the most appropriate treatment?
A. Carbimazole.
B. Propranolol only.
C. Levothyroxine.
D. Insulin glargine.
E. Hydrocortisone cream.
15. A 21-year-old woman with type 1 diabetes presents with vomiting, abdominal pain and deep breathing. Blood glucose is 24 mmol/L and blood ketones are raised.
Which ONE of the following is the most appropriate immediate management?
A. Treat as mild hypoglycaemia.
B. Treat as suspected diabetic ketoacidosis and arrange urgent hospital management.
C. Give gliclazide.
D. Stop insulin and encourage oral fluids only.
E. Diagnose uncomplicated viral illness.
16. An 83-year-old woman with type 2 diabetes is admitted with severe dehydration, confusion and blood glucose of 38 mmol/L. Ketones are not significantly raised.
Which ONE of the following is the most likely diagnosis?
A. Primary hypothyroidism.
B. Addison’s disease.
C. Mild hypoglycaemia.
D. Hyperosmolar hyperglycaemic state.
E. Thyroid storm.
17. A 38-year-old woman with gestational diabetes is struggling to achieve glucose targets despite diet and exercise. She asks why pharmacological treatment is being considered.
Which ONE of the following is the most appropriate explanation?
A. Optimising glucose reduces risks to both mother and baby.
B. Gestational diabetes never requires medicines.
C. Treatment is only needed after delivery.
D. Hyperglycaemia in pregnancy is harmless.
E. Medicines are used only to treat morning sickness.
18. A 74-year-old woman is prescribed alendronic acid once weekly for osteoporosis. She asks how to take it.
Which ONE of the following advice is most appropriate?
A. Take it at bedtime with milk.
B. Take it after breakfast with tea.
C. Crush it and mix with yoghurt.
D. Take it with calcium tablets at the same time.
E. Take it on an empty stomach with a full glass of water and remain upright afterwards.
19. A 68-year-old man taking long-term oral corticosteroids has not been assessed for fracture risk. He has recently had a low-trauma wrist fracture.
Which ONE of the following is the most appropriate pharmacist intervention?
A. Reassure him that corticosteroids protect bone.
B. Stop corticosteroids abruptly.
C. Recommend assessment of osteoporosis and fracture risk.
D. Advise avoiding calcium-rich foods.
E. Start high-dose levothyroxine.
20. A 72-year-old woman taking alendronic acid reports new severe thigh pain that has developed gradually over several weeks. She has been taking treatment for several years.
Which ONE of the following is the most appropriate concern?
A. Severe hypoglycaemia.
B. Possible atypical femoral fracture requiring assessment.
C. Carbimazole toxicity.
D. Thyroid storm.
E. Hyperosmolar state.
21. A 34-year-old man with known Addison’s disease develops vomiting and diarrhoea and is unable to keep his oral hydrocortisone down. He feels weak and dizzy.
Which ONE of the following is the most appropriate action?
A. Omit hydrocortisone until vomiting stops.
B. Take an antacid and wait 48 hours.
C. Double levothyroxine.
D. Use gliclazide for energy.
E. Seek urgent medical help because adrenal crisis may develop.
22. A 58-year-old woman has been taking prednisolone 40 mg daily for three weeks. She asks whether she can stop it today because her symptoms have improved.
Which ONE of the following is the most appropriate advice?
A. Stop immediately without review.
B. Replace prednisolone with ibuprofen.
C. Do not stop suddenly; discuss a tapering plan with the prescriber.
D. Take it only on alternate days without advice.
E. Double the dose before stopping.
23. A 67-year-old man with type 2 diabetes is taking insulin glargine 24 units at night. His fasting glucose readings over the past week are 3.1, 3.4, 3.6, 3.3 and 3.5 mmol/L. Pre-evening meal readings are 8–10 mmol/L.
Which ONE of the following is the most appropriate interpretation?
A. Basal insulin may be too high and should be reviewed.
B. Rapid-acting insulin before lunch must always be increased.
C. This is optimal control and needs no review.
D. Metformin is causing fasting hypoglycaemia.
E. He should stop all diabetes treatment.
24. A 44-year-old woman using insulin tells you she stores her spare insulin pens in the freezer to make them last longer.
Which ONE of the following is the most appropriate advice?
A. Freezing improves insulin potency.
B. Insulin should not be frozen; spare supplies should be stored as recommended by the manufacturer.
C. Frozen insulin should be warmed in boiling water.
D. Freezing is only unsafe for rapid-acting insulin.
E. Insulin storage conditions do not matter.
25. A 71-year-old man taking gliclazide usually eats breakfast before his morning dose. He is fasting for a procedure and asks whether he should take the tablet as normal.
Which ONE of the following is the most appropriate advice?
A. Take extra gliclazide because he is fasting.
B. Replace gliclazide with alcohol.
C. Take the dose only if glucose is below 4 mmol/L.
D. Seek advice on withholding or adjusting gliclazide because fasting increases hypoglycaemia risk.
E. Double the next dose after the procedure.
26. A 25-year-old man with type 1 diabetes is unwell with a chest infection. His blood glucose is 17 mmol/L and ketones are positive. He has been taking less insulin because he is eating less.
Which ONE of the following is the most appropriate advice?
A. Stop insulin completely while appetite is reduced.
B. Continue insulin, follow sick-day rules and seek urgent advice due to ketones.
C. Treat with gliclazide.
D. Ignore ketones if glucose is below 20 mmol/L.
E. Drink sugary drinks only.
27. A 62-year-old man with diabetes presents to the pharmacy with a red, hot, swollen foot ulcer and feels generally unwell. He has reduced sensation in both feet.
Which ONE of the following is the most appropriate action?
A. Sell an antifungal cream.
B. Advise routine podiatry review in three months.
C. Arrange urgent medical assessment for possible infected diabetic foot ulcer.
D. Recommend only new footwear.
E. Reassure because neuropathy makes infection unlikely.
28. A 59-year-old woman with type 2 diabetes asks whether she needs home blood glucose monitoring. She takes metformin only, has no hypoglycaemic symptoms and is not pregnant.
Which ONE of the following is the most appropriate advice?
A. Everyone with type 2 diabetes must test four times daily.
B. Routine self-monitoring is not usually needed in this situation.
C. Testing is required before every dose of metformin.
D. Monitoring replaces HbA1c testing.
E. Testing is only useful if glucose is below 2 mmol/L.
29. A 64-year-old man with type 2 diabetes and albuminuria asks why his blood pressure treatment is being reviewed carefully.
Which ONE of the following is the most appropriate explanation?
A. Diabetes with albuminuria increases kidney and cardiovascular risk, so blood pressure and renal protection are important.
B. Albuminuria means blood pressure medicines should always be stopped.
C. Albuminuria is unrelated to diabetes.
D. Blood pressure control has no effect on kidney risk.
E. Only thyroid medicines protect the kidneys.
30. A 53-year-old man with type 2 diabetes is prescribed sitagliptin. He is also being considered for a GLP-1 receptor agonist because his HbA1c remains high.
Which ONE of the following is the most appropriate medicines optimisation issue?
A. Sitagliptin and GLP-1 receptor agonists are always combined for maximum effect.
B. Sitagliptin prevents all gastrointestinal adverse effects.
C. Sitagliptin should be replaced with insulin in all cases.
D. Combining a DPP-4 inhibitor with a GLP-1 receptor agonist is generally not appropriate.
E. GLP-1 receptor agonists are used only for hypoglycaemia rescue.
31. A 48-year-old woman with type 2 diabetes has recurrent genital thrush after starting an SGLT2 inhibitor. Her glucose control and renal function have improved.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Explain that genital infections can occur with SGLT2 inhibitors and arrange review if recurrent or severe.
B. Increase the SGLT2 inhibitor dose without review.
C. Add gliclazide to treat thrush.
D. Reassure that symptoms are unrelated.
E. Stop all diabetes medicines permanently.
32. A 69-year-old woman with hypothyroidism takes levothyroxine. She has started ferrous sulfate for iron deficiency anaemia and now feels tired again. Her TSH has increased.
Which ONE of the following is the most appropriate advice?
A. Stop levothyroxine.
B. Take ferrous sulfate and levothyroxine at the same time.
C. Ferrous sulfate can reduce levothyroxine absorption, so administration times should be separated.
D. Iron deficiency cures hypothyroidism.
E. Double levothyroxine without review.
33. A 60-year-old man taking amiodarone develops weight loss, tremor and palpitations. Thyroid function tests show suppressed TSH and raised free T4.
Which ONE of the following is the most appropriate concern?
A. Amiodarone has no thyroid effects.
B. Primary adrenal failure.
C. Amiodarone-associated thyrotoxicosis.
D. Metformin toxicity.
E. Osteoporosis.
34. A 45-year-old woman takes lithium for bipolar disorder. Routine blood tests show raised TSH and low free T4.
Which ONE of the following is the most appropriate interpretation?
A. Lithium cannot affect thyroid function.
B. The results suggest possible hypothyroidism requiring clinical review.
C. The results confirm diabetic ketoacidosis.
D. Thyroid tests should be ignored.
E. The patient should start carbimazole without review.
35. A 29-year-old woman with type 1 diabetes is found unconscious. Her capillary blood glucose is 2.1 mmol/L and she is unable to swallow safely.
Which ONE of the following is the most appropriate immediate management?
A. Give rapid-acting carbohydrate orally.
B. Give gliclazide.
C. Wait for spontaneous recovery.
D. Administer glucagon or intravenous glucose according to local protocol.
E. Give extra rapid-acting insulin.
36. A 73-year-old man with type 2 diabetes is started on prednisolone 40 mg daily for an acute inflammatory condition. He has previously had stable glucose readings.
Which ONE of the following is the most appropriate consideration?
A. Prednisolone usually lowers blood glucose.
B. Prednisolone can worsen hyperglycaemia and glucose monitoring or treatment adjustment may be needed.
C. Prednisolone prevents diabetes complications.
D. Diabetes monitoring can stop during steroid treatment.
E. Prednisolone treats hypoglycaemia directly.
37. A 66-year-old woman takes long-term oral prednisolone. She is brought to hospital with severe vomiting, hypotension and confusion. Her family report that she stopped prednisolone abruptly one week ago.
Which ONE of the following is the most appropriate concern?
A. Thyroid storm.
B. Hyperosmolar state.
C. Osteomalacia only.
D. Adrenal crisis due to abrupt steroid withdrawal.
E. Uncomplicated reflux.
38. A 71-year-old woman is prescribed alendronic acid for osteoporosis. She has severe oesophageal reflux and cannot remain upright for more than a few minutes because of severe frailty.
Which ONE of the following is the most appropriate pharmacist action?
A. Advise crushing alendronic acid.
B. Recommend taking it at bedtime.
C. Review suitability of oral bisphosphonate therapy and discuss alternatives with the prescriber.
D. Take it with milk.
E. Take it with the evening meal.
39. A 58-year-old man has recurrent renal stones, constipation, bone pain and corrected calcium above the reference range.
Which ONE of the following endocrine condition should be considered?
A. Primary hyperparathyroidism.
B. Type 1 diabetes.
C. Addison’s disease.
D. Primary hypothyroidism.
E. Hypoglycaemia.
40. A 40-year-old woman with known Addison’s disease presents with severe weakness, abdominal pain, vomiting, hypotension and confusion.
Which ONE of the following is the most appropriate immediate management?
A. Arrange routine GP review.
B. Give carbimazole.
C. Treat as adrenal crisis requiring urgent hydrocortisone and supportive emergency care.
D. Give gliclazide.
E. Stop all steroid replacement permanently.
41. A 78-year-old woman with type 2 diabetes takes insulin and has had two episodes of severe hypoglycaemia in the last month. She lives alone and is anxious about another episode.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Recommend review of insulin regimen, hypoglycaemia awareness, monitoring and rescue plan.
B. Tell her to stop eating carbohydrates completely.
C. Increase insulin doses.
D. Reassure that severe hypoglycaemia is harmless.
E. Stop all diabetes monitoring.
42. A 35-year-old man with type 1 diabetes is training for a long-distance cycling event. He asks why he keeps having hypos during prolonged exercise.
Which ONE of the following is the most appropriate explanation?
A. Exercise always raises glucose.
B. Physical activity can increase glucose use and may require planned carbohydrate intake or insulin adjustment.
C. Hypos during exercise prove he does not have diabetes.
D. Basal insulin should always be stopped permanently.
E. Exercise prevents all future hypoglycaemia.
43. A 26-year-old woman with type 1 diabetes is started on a beta-blocker for migraine prevention. She asks whether this affects her diabetes.
Which ONE of the following counselling point is most appropriate?
A. Beta-blockers always cause ketoacidosis.
B. Beta-blockers cure hypoglycaemia.
C. Beta-blockers may mask some adrenergic symptoms of hypoglycaemia.
D. Beta-blockers replace insulin.
E. Beta-blockers prevent ketone production.
44. A 66-year-old man with type 2 diabetes and established cardiovascular disease is taking an SGLT2 inhibitor. His HbA1c remains above target and he is being assessed for injectable therapy.
Which ONE of the following factor is most relevant when considering a GLP-1 receptor agonist?
A. It is used only to treat hypoglycaemia.
B. It must always be combined with a DPP-4 inhibitor.
C. It is contraindicated solely because he has cardiovascular disease.
D. Potential benefits on weight, HbA1c and cardiovascular risk should be considered.
E. It has no gastrointestinal adverse effects.
45. A 77-year-old woman takes levothyroxine. Her TSH is suppressed on repeated testing and she has developed palpitations. She has a history of osteoporosis.
Which ONE of the following is the most appropriate concern?
A. Levothyroxine under-replacement.
B. Carbimazole-induced agranulocytosis.
C. Possible over-replacement increasing risks such as arrhythmia and bone loss.
D. Metformin-associated lactic acidosis.
E. Addison’s disease.
46. A 70-year-old man with type 2 diabetes takes metformin and an SGLT2 inhibitor. He is admitted with acute kidney injury and poor oral intake.
Which ONE of the following is the most appropriate medicines optimisation issue?
A. Metformin and SGLT2 inhibitor should be reviewed and may need temporary withholding during acute illness.
B. Both medicines must be doubled.
C. Acute kidney injury improves metformin clearance.
D. SGLT2 inhibitors prevent dehydration.
E. No review is needed.
47. A 39-year-old woman using an SGLT2 inhibitor for type 2 diabetes is booked for elective surgery. She asks whether she should continue all diabetes medicines as normal.
Which ONE of the following is the most appropriate advice?
A. Continue SGLT2 inhibitor without telling the surgical team.
B. Take extra SGLT2 inhibitor on the day of surgery.
C. Replace all medicines with gliclazide.
D. Ask the surgical team for peri-operative advice because SGLT2 inhibitors may need temporary withholding to reduce ketoacidosis risk.
E. Stop all diabetes treatment permanently.
48. A 31-year-old woman taking semaglutide for type 2 diabetes becomes pregnant and contacts the pharmacy for advice.
Which ONE of the following is the most appropriate pharmacist action?
A. Advise urgent clinical review because diabetes medicines often need adjustment in pregnancy.
B. Reassure that no review is needed.
C. Double the semaglutide dose.
D. Add a DPP-4 inhibitor.
E. Stop all diabetes treatment without contacting her specialist team.
49. A 62-year-old man with type 2 diabetes has painful peripheral neuropathy. He is already taking amitriptyline, which has improved symptoms but causes troublesome dry mouth and constipation.
Which ONE of the following is the most appropriate next step?
A. Add oxybutynin.
B. Increase amitriptyline despite intolerable adverse effects.
C. Review treatment and consider an alternative neuropathic pain option if adverse effects outweigh benefit.
D. Stop all diabetes treatment.
E. Treat with antibiotics.
50. A 74-year-old woman is prescribed desmopressin for nocturia by a specialist. She later develops headache, confusion and nausea. Blood tests show hyponatraemia.
Which ONE of the following is the most appropriate concern?
A. Desmopressin prevents hyponatraemia.
B. The symptoms are unrelated to sodium.
C. Hyponatraemia cannot cause confusion.
D. Desmopressin should be doubled.
E. Desmopressin-associated hyponatraemia requires urgent review.
Endocrine Questions
Answers and Rationale
1. C
This patient has type 2 diabetes with established cardiovascular disease and chronic kidney disease. Metformin and an SGLT2 inhibitor may be appropriate as part of initial therapy, provided renal function and contraindications are considered.
2. E
Metformin should be reviewed during acute illness with vomiting, diarrhoea or dehydration because renal function can deteriorate and the risk of lactic acidosis may increase. Temporary withholding and clinical advice are appropriate.
3. A
SGLT2 inhibitors can rarely be associated with diabetic ketoacidosis, including euglycaemic or near-euglycaemic presentations. Raised ketones with vomiting and abnormal breathing require urgent assessment.
4. D
Repeated early morning hypoglycaemia suggests nocturnal hypoglycaemia and possible excessive basal insulin. The basal regimen should be reviewed rather than increased.
5. B
Gliclazide is a sulfonylurea and can cause hypoglycaemia, especially when meals are missed or delayed. Sweating, shaking and confusion with glucose below 4 mmol/L support this.
6. E
Persistent severe abdominal pain radiating to the back with vomiting raises concern for pancreatitis. GLP-1 receptor agonist therapy should be reviewed urgently and the patient medically assessed.
7. A
Pioglitazone can cause fluid retention and may worsen or precipitate heart failure. It is generally unsuitable in patients with established heart failure.
8. D
People with type 1 diabetes usually need to continue basal insulin during illness, even if eating less. Sick-day guidance includes hydration, glucose monitoring and ketone testing where appropriate.
9. B
Long-term oral corticosteroids can suppress the hypothalamic-pituitary-adrenal axis. During severe illness such as sepsis, stress-dose corticosteroid cover may be required.
10. C
Calcium can reduce levothyroxine absorption if taken too close together. Administration times should be separated and thyroid function monitored if control has changed.
11. D
Carbimazole can rarely cause agranulocytosis. Fever, sore throat and mouth ulcers are warning symptoms requiring immediate cessation and urgent blood count assessment.
12. A
Weight loss, heat intolerance, tremor and palpitations with suppressed TSH and raised free T4 are consistent with hyperthyroidism.
13. E
Suppressed TSH and raised free T4 in a patient taking levothyroxine suggest over-replacement. This can increase risks such as atrial fibrillation and bone loss, especially in older adults.
14. C
Raised TSH with low free T4 is consistent with primary hypothyroidism. Levothyroxine is the standard replacement treatment, with dose individualised and monitored.
15. B
Vomiting, abdominal pain, deep breathing, hyperglycaemia and raised ketones are features of diabetic ketoacidosis. This requires urgent hospital management.
16. D
Severe hyperglycaemia, dehydration and confusion without significant ketonaemia in an older person with type 2 diabetes is consistent with hyperosmolar hyperglycaemic state.
17. A
Treating gestational diabetes reduces risks associated with maternal hyperglycaemia, including complications for both mother and baby. Medicines may be required if lifestyle measures are insufficient.
18. E
Alendronic acid should be taken on an empty stomach with water, and the patient should remain upright afterwards to reduce oesophageal irritation and improve absorption.
19. C
Long-term corticosteroids increase fracture risk. A low-trauma fracture should prompt assessment for osteoporosis and consideration of bone-protective treatment.
20. B
New thigh or groin pain in a patient on long-term bisphosphonate therapy may suggest an atypical femoral fracture. Clinical assessment is required.
21. E
Vomiting and inability to keep hydrocortisone down in Addison’s disease can precipitate adrenal crisis. Urgent medical treatment is needed, often including parenteral hydrocortisone.
22. C
After several weeks of systemic corticosteroid treatment, abrupt withdrawal can risk adrenal insufficiency. A prescriber-led tapering plan may be needed.
23. A
Repeated fasting hypoglycaemia suggests the basal insulin dose may be too high. The insulin regimen should be reviewed to reduce hypoglycaemia risk.
24. B
Insulin should not be frozen because freezing can damage the product and affect potency. Storage should follow the manufacturer’s instructions.
25. D
Sulfonylureas increase insulin secretion and can cause hypoglycaemia when food intake is reduced. Fasting for a procedure should prompt advice on dose adjustment or withholding.
26. B
People with type 1 diabetes should not stop insulin during illness. Positive ketones with hyperglycaemia require urgent advice because of the risk of diabetic ketoacidosis.
27. C
A red, hot, swollen diabetic foot ulcer with systemic symptoms suggests infection and requires urgent assessment. Neuropathy can mask severity and delay presentation.
28. B
Routine self-monitoring of blood glucose is not usually required for adults with type 2 diabetes treated with metformin alone, unless there are specific clinical indications.
29. A
Albuminuria in diabetes is a marker of kidney and cardiovascular risk. Optimising blood pressure and renal-protective therapy is important to reduce complications.
30. D
DPP-4 inhibitors and GLP-1 receptor agonists act on related incretin pathways and are generally not used together. Treatment should be rationalised rather than duplicated.
31. A
SGLT2 inhibitors increase urinary glucose and can predispose to genital mycotic infections. Recurrent or severe symptoms should prompt review of treatment suitability and counselling.
32. C
Iron salts can reduce levothyroxine absorption. Separating administration times and monitoring thyroid function can help restore control.
33. C
Amiodarone can cause thyroid dysfunction, including thyrotoxicosis. Symptoms with suppressed TSH and raised free T4 require clinical review.
34. B
Lithium can affect thyroid function and may cause hypothyroidism. Raised TSH with low free T4 should prompt clinical review and management.
35. D
Severe hypoglycaemia in a person unable to swallow safely requires glucagon or intravenous glucose according to local protocol, rather than oral carbohydrate.
36. B
Systemic corticosteroids can worsen blood glucose control. People with diabetes may need additional monitoring and treatment adjustment during steroid therapy.
37. D
Abrupt withdrawal of long-term corticosteroids can precipitate adrenal insufficiency or adrenal crisis, particularly during acute illness. Hypotension, vomiting and confusion are concerning features.
38. C
Oral bisphosphonates require the patient to remain upright and can irritate the oesophagus. If this is not possible, suitability should be reviewed and alternatives considered.
39. A
Hypercalcaemia with renal stones, constipation and bone pain is suggestive of primary hyperparathyroidism. Further clinical assessment and investigation are needed.
40. C
Known Addison’s disease with vomiting, hypotension, abdominal pain and confusion suggests adrenal crisis. Urgent hydrocortisone and supportive emergency treatment are required.
41. A
Recurrent severe hypoglycaemia in an older person living alone requires review of insulin regimen, awareness, monitoring, rescue treatment and individualised glycaemic targets.
42. B
Exercise can increase glucose utilisation and cause hypoglycaemia, especially in people using insulin. Planned carbohydrate intake, monitoring and insulin adjustment may be needed.
43. C
Beta-blockers can mask adrenergic warning symptoms of hypoglycaemia such as tremor and palpitations. Patients should be counselled to monitor carefully and recognise alternative symptoms.
44. D
GLP-1 receptor agonists may improve HbA1c and weight, and some have cardiovascular benefits. They should not generally be combined with DPP-4 inhibitors.
45. C
Suppressed TSH with palpitations suggests levothyroxine over-replacement. In older adults, this can increase the risk of arrhythmias and bone loss.
46. A
During acute illness with acute kidney injury and reduced intake, metformin and SGLT2 inhibitors should be reviewed and may need temporary withholding to reduce harm.
47. D
SGLT2 inhibitors may need to be stopped around surgery because of the risk of ketoacidosis. The patient should follow peri-operative advice from the surgical or diabetes team.
48. A
Pregnancy requires urgent specialist review of diabetes medicines and glycaemic control. Medicines may need to be changed to options with established pregnancy safety.
49. C
Amitriptyline can cause antimuscarinic adverse effects such as dry mouth and constipation. If adverse effects are troublesome, the treatment should be reviewed and alternatives considered.
50. E
Desmopressin can cause water retention and hyponatraemia. Headache, nausea and confusion with low sodium require urgent clinical review.
Here are 50 multiple-choice questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.