🎯 Theme 4 Exam Practice

A 50-year-old man with severe obesity and poorly controlled type 2 diabetes is referred for consideration of metabolic surgery after unsuccessful structured non-surgical management. He has hypertension and significant limitations in daily activity. Which potential benefit provides an important clinical rationale for metabolic surgery?

A 58-year-old woman presents with severe fatigue and reduced appetite. She has a history of pituitary surgery for a large non-functioning adenoma. Investigations reveal low serum cortisol and low plasma ACTH. Serum potassium is normal. Which physiological explanation best accounts for the preserved potassium concentration?

A 35-year-old woman has confirmed pituitary ACTH-dependent Cushing’s disease following appropriate endocrine evaluation. She has progressive proximal myopathy, hypertension and menstrual irregularity. Her pituitary lesion is considered surgically treatable. Which is the preferred definitive management approach?

A 39-year-old woman with confirmed Cushing’s syndrome develops worsening hypertension and impaired glucose tolerance. Laboratory tests reveal fasting hyperglycaemia despite no previous history of diabetes. Which metabolic action of cortisol most directly contributes to this abnormality?

A 48-year-old man undergoes successful surgery for a cortisol-producing adrenal adenoma. During the early postoperative period, he develops fatigue, nausea and low blood pressure. His morning cortisol concentration is markedly reduced. Which explanation best accounts for this postoperative finding?

A 39-year-old woman with progressive Cushingoid features has repeatedly elevated cortisol measurements. Subsequent plasma ACTH testing demonstrates a markedly suppressed concentration. Which underlying mechanism is most consistent with this biochemical pattern?

A 41-year-old woman with untreated Cushing’s syndrome presents with sudden pleuritic chest pain, shortness of breath and tachycardia. She has hypertension, diabetes and reduced mobility from proximal myopathy. Which complication should be considered urgently?

A 42-year-old woman with a BMI of 37 kg/m² has type 2 diabetes, hypertension and dyslipidaemia. Despite a structured programme of dietary modification, physical activity and behavioural support, she has not achieved sustained weight reduction. Her clinician considers adding anti-obesity pharmacotherapy. Which principle should guide this decision?

A 29-year-old woman with obesity, irregular menstruation and increased facial hair is referred for suspected Cushing’s syndrome. She has no easy bruising, proximal weakness or abnormal striae. Her blood pressure and glucose are normal. Which alternative diagnosis should receive particular consideration?

A 43-year-old woman with confirmed ACTH-dependent Cushing’s syndrome undergoes pituitary MRI, which reveals a small pituitary lesion. She has hypertension, diabetes mellitus and progressive muscle wasting. The endocrinology team confirms that the pituitary lesion is responsible for the cortisol excess. Which treatment offers the best prospect of definitive control?

A 35-year-old woman with obesity presents for evaluation after gaining considerable weight over the previous year. She reports reduced physical activity, poor sleep and increasing stress. Examination reveals no specific features of an endocrine disorder. Her clinician discusses the multifactorial causes of obesity. Which explanation best reflects the biological basis of her condition?

A 32-year-old woman with obesity seeks treatment because of increasing fatigue and difficulty maintaining physical activity. She reports irregular menstrual cycles and difficulty conceiving. Examination reveals acanthosis nigricans. Which metabolic abnormality most plausibly links her obesity to these reproductive manifestations?

A 34-year-old woman with a history of prolonged high-dose glucocorticoid treatment is undergoing a supervised dose reduction. She develops an acute respiratory infection with high fever and reduced oral intake. Her physician is concerned about inadequate endogenous cortisol production during physiological stress. Which management principle is most appropriate?

A 36-year-old woman with confirmed Cushing’s syndrome has hypertension, diabetes, proximal myopathy and reduced functional capacity. She is clinically stable while awaiting specialist evaluation of a suspected pituitary source. Which management strategy is most appropriate?

A 48-year-old woman with chronic hypercortisolism reports sudden severe back pain after lifting a light household object. She has progressive proximal muscle weakness and loss of height over the preceding year. Which complication most appropriately explains this presentation?

A 35-year-old woman with progressive truncal obesity reports difficulty standing from a low chair and climbing stairs. Examination reveals symmetrical proximal muscle weakness with preserved distal strength and sensation. Which mechanism best explains her muscle dysfunction in the context of suspected hypercortisolism?

A 36-year-old woman has clinically and biochemically confirmed endogenous Cushing’s syndrome. Her plasma ACTH concentration is 48 pg/mL despite elevated cortisol levels. Which conclusion is most appropriate before proceeding with localization investigations?

A 45-year-old woman has been taking prednisolone for a chronic inflammatory condition for several years. She has developed central obesity, facial rounding and proximal muscle weakness. Her original disease is now controlled, and glucocorticoid withdrawal is being considered. Which approach is most appropriate?

A 38-year-old woman presents with progressive weight gain, facial rounding and reduced physical strength. Examination reveals supraclavicular fullness, a dorsocervical fat pad and marked proximal muscle wasting. Which interpretation best explains this combination of findings?

A 46-year-old woman with progressive central obesity, facial rounding and hypertension undergoes initial endocrine evaluation. Two appropriately performed screening tests suggest hypercortisolism. Before proceeding to pituitary or adrenal imaging, which approach is most appropriate?

A 62-year-old man with chronic pulmonary tuberculosis develops progressive weakness, reduced appetite and postural hypotension. Biochemical evaluation confirms primary adrenal insufficiency. Abdominal imaging demonstrates bilateral adrenal abnormalities. Which pathological mechanism most plausibly explains the endocrine disorder?

A 47-year-old man with central obesity, hypertension and impaired fasting glucose undergoes laboratory assessment. His triglycerides are elevated and HDL cholesterol is reduced. Which underlying mechanism best links these abnormalities?

A 37-year-old woman with suspected Cushing’s syndrome has blood pressure of 158/94 mmHg, fasting plasma glucose of 142 mg/dL and serum potassium of 3.4 mmol/L. She also has central obesity, easy bruising and proximal myopathy. Which interpretation best integrates these biochemical and clinical findings?

A 56-year-old man presents with severe hypertension, recently diagnosed diabetes, hypokalaemia and rapidly progressive muscle weakness. Investigations confirm markedly elevated cortisol and ACTH concentrations. Chest imaging identifies a suspicious pulmonary mass. Which mechanism best explains the endocrine abnormalities?

A 40-year-old woman presents with progressive central obesity, facial rounding, muscle weakness and hypertension. She has been receiving treatment for chronic respiratory disease for several years. Before arranging biochemical investigations for endogenous Cushing’s syndrome, which additional history is most important?

A 44-year-old woman with newly diagnosed primary adrenal insufficiency also has untreated primary hypothyroidism. She is clinically stable but reports severe fatigue and cold intolerance. Her physician plans replacement treatment for both endocrine disorders. Which sequence is safest?

A 36-year-old woman has progressive central obesity, facial plethora, wide violaceous abdominal striae, proximal myopathy and hypertension. She denies corticosteroid exposure. The physician suspects endogenous Cushing’s syndrome. Which is the most appropriate next diagnostic approach?

A 45-year-old woman presents with fatigue, weight loss and recurrent dizziness. Investigations establish primary adrenal insufficiency. Further testing identifies antibodies against 21-hydroxylase. She also has a history of autoimmune thyroid disease. Which underlying cause is most likely?

A 41-year-old woman with obesity and hypertension begins a structured weight-management programme. After several months, she achieves a clinically meaningful reduction in body weight, accompanied by improved blood pressure and glycaemic control. Which approach is most appropriate for sustaining these benefits?

A woman with characteristic Cushingoid features undergoes an overnight 1-mg dexamethasone suppression test. The following morning, her serum cortisol concentration is 12 µg/dL. No major test interference is identified. Which interpretation is most appropriate?

A woman with confirmed endogenous ACTH-dependent Cushing’s syndrome undergoes pituitary MRI, which reveals a 7-mm lesion. She has proximal myopathy, hypertension and diabetes. Which is the most appropriate interpretation of the imaging result?

A 29-year-old woman with autoimmune primary adrenal insufficiency attends a routine follow-up appointment. She takes prescribed replacement therapy and asks how to reduce her risk of deterioration during future illnesses. Which counselling recommendation is most appropriate?

A 36-year-old woman reports progressive weight gain over 18 months, irregular menstruation and weakness while climbing stairs. She has recently developed hypertension. Her BMI is 31 kg/m², and she has predominantly abdominal fat accumulation. Which additional historical feature would most strongly support pathological cortisol excess rather than uncomplicated obesity?

Two women with similar BMI values of 32 kg/m² are assessed for progressive weight gain. The first has generalized adiposity without other abnormalities. The second has central obesity, recently developed hypertension and menstrual irregularity. Which additional examination finding in the second patient would most strongly distinguish Cushing’s syndrome from uncomplicated obesity?

A 36-year-old woman with established primary adrenal insufficiency takes hydrocortisone and fludrocortisone regularly. At follow-up, she reports persistent salt craving and dizziness when standing. Examination reveals low blood pressure, and laboratory testing demonstrates mild hyperkalaemia. Which aspect of her treatment requires particular reassessment?

A woman undergoes successful transsphenoidal surgery for confirmed pituitary Cushing’s disease. During early postoperative assessment, she develops marked fatigue, nausea and low blood pressure, with a low serum cortisol concentration. Which management principle is most appropriate?

A 54-year-old man with obesity, hypertension and type 2 diabetes is diagnosed with metabolic dysfunction-associated steatotic liver disease after evaluation of persistently elevated liver enzymes. He consumes minimal alcohol. Which process most directly contributes to hepatic fat accumulation in this condition?

A 42-year-old woman with progressive central obesity, proximal muscle weakness and bruising has elevated late-night salivary cortisol on repeated testing. Her physician explains that these results support endogenous hypercortisolism. Which physiological disturbance is demonstrated by these findings?

A 51-year-old woman with longstanding endogenous Cushing’s syndrome presents after sustaining a vertebral compression fracture following minimal trauma. She has no history of significant injury. Which pathological process best explains her increased fracture risk?

A 37-year-old woman returns for follow-up six months after treatment of pituitary Cushing’s disease. Her facial appearance has improved, but she remains concerned about muscle weakness and persistent hypertension. She asks whether further appointments are necessary now that the cortisol excess has been treated. Which counselling advice is most appropriate?