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SEND - Endocrinology and Diabetes (Specialty Certificate Examination) Questions 56–60 (page: 13)

A 73-year-old man had been attending the diabetes clinic for 6 weeks with an ulcer on his right second metatarsal head. He had been receiving regular podiatry and offloading.
What new feature in the appearance of his foot is most likely to suggest the need to start antibiotics?

A 48-year-old man was referred by his general practitioner, whose letter stated: ‘Please review this man’s blood pressure management, as he has requested a second opinion, having seen information on the internet about the need for more detailed investigation. He has been having treatment for 10 years.’
At the consultation, the patient confirmed that he was currently taking bendroflumethiazide 2.5 mg daily, atenolol 50 mg daily and perindopril 8 mg daily. His clinic blood pressure was 169/108 mmHg. Clinical examination was otherwise normal.

Investigations:
-serum sodium142 mmol/L (137–144) serum potassium3.9 mmol/L (3.5–4.9)
-estimated glomerular filtration rate (MDRD)>60 mL/min/1.73 m2 (>60) ambulant plasma renin activity0.5 pmol/mL/h (3.0–4.3)
-ambulant plasma aldosterone380 pmol/L (330–830)

What is the most appropriate next step in management?

A 52-year-old man had been found to have type 1 diabetes mellitus at the age of 25. He had developed retinopathy at the age of 31 and a painless foot ulcer at the age of 40. His renal function had subsequently deteriorated.
On examination, urinalysis showed protein 1+, glucose 2+. What is the most likely diagnosis?

A 42-year-old motor mechanic was referred to the dermatologist with small cauliflower-like deposits on the points of his elbows. He was generally well, but on systemic enquiry, he described intermittent claudication. He had previously been hypertensive, and was taking thyroxine for primary hypothyroidism.
On examination, he was moderately obese. He had xanthelasmata on the upper eyelids of both eyes and tuberoeruptive xanthomata on both elbows, both knees and the nape of the neck.

Investigations:
-serum alanine aminotransferase78 U/L (5–35) fasting plasma glucose7.8 mmol/L (3.0–6.0) serum urate0.48 mmol/L (0.23–0.46)
-serum cholesterol13.4 mmol/L (<5.2) serum LDL cholesterolnot measurable
-serum HDL cholesterol0.90 mmol/L (>1.55) fasting serum triglycerides9.32 mmol/L (0.45–1.69)
-apolipoprotein E genotypehomozygous for apolipoprotein E2

What is the most likely diagnosis?

A 17-year-old girl was referred to the outpatient clinic with irritability, weight loss and difficulty sleeping. At the age of 4, she had presented with rapid growth, breast development and vaginal bleeding. The results of a gonadotropin-releasing hormone (GnRH) stimulation test performed at that time are given below.

serum oestradiolplasma FSHplasma LH (200–400 pmol/L)(2.5–10.0 U/L)(2.5–10.0 U/L) 0 min365<0.7<0.5
30 min–<0.7<0.5
60 min–<0.7<0.5

She had been treated with GnRH analogue until the age of 11 and puberty had then progressed normally.
On examination, she was found to be tremulous, tachycardic and hyper-reflexic. Several large, irregular café- au-lait spots were found.

Investigations:
serum thyroid-stimulating hormone<0.05 mU/L (0.4–5.0) serum free T436.0 pmol/L (10.0–22.0)
What is the most likely diagnosis?