QUESTION: 21

A 37-year-old woman presented with a 2-year history of increasingly frequent flushing episodes. She described alternating loose bowel motions and constipation. She had also noted menstrual irregularity. She had no respiratory symptoms. She denied headache or chest pain, but complained of palpitations.
On examination, she appeared well. Her blood pressure was 128/82 mmHg. Investigations:
serum thyroid-stimulating hormone0.8 mU/L (0.4–5.0) What is the most appropriate next investigation?

fasting plasma gut hormones
plasma metanephrines
serum gonadotrophins
urinary 5-hydroxyindoleacetic acid
urinary metanephrines

Answer(s): C

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QUESTION: 22

A 47-year-old nuclear physics professor was referred for advice before taking up an overseas position, overseeing the dismantling of a reactor at the site of a recent nuclear accident. She stated that she would face a small risk of being exposed to significant radioactive contamination during her work and was concerned about her future risk of thyroid cancer.
What is the most appropriate advice?

avoid consuming local milk and vegetables
no precautions are necessary for people aged 40 years or over
take potassium iodide tablets
take selenium tablets
wear lead neck shield while outdoors

Answer(s): C

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QUESTION: 23

A 19-year-old man was seen in the diabetes clinic. He had lost 2 kg in weight since the diagnosis of diabetes mellitus 18 months previously. At presentation, his body mass index was 33 kg/m2 (18–25), his random plasma glucose was 18.0 mmol/L and his haemoglobin A1c was 56 mmol/mol (20–42). He was taking gliclazide, and metformin had been added later. His father and grandfather had developed diabetes mellitus during their twenties.
Investigations:

haemoglobin A1c56 mmol/mol (20–42) serum C-peptide301 pmol/L (180–360) anti-glutamic acid decarboxylase (GAD) antibodiesnegative

What is the most likely diagnosis?

chronic pancreatitis
latent-onset diabetes of autoimmunity
maturity-onset diabetes of the young
type 1 diabetes mellitus
type 2 diabetes mellitus

Answer(s): C

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QUESTION: 24

A 48-year-old man with an 8-year history of type 2 diabetes mellitus was referred because of poor glycaemic control. He had a history of myocardial infarction complicated by previous congestive cardiac failure. His current medication comprised metformin 850 mg three times daily and gliclazide 80 mg once daily. He had gained weight and his body mass index was 31 kg/m2 (18–25).

Investigations:
serum sodium143 mmol/L (137–144) serum potassium4.4 mmol/L (3.5–4.9) serum creatinine136 µmol/L (60–110) haemoglobin A1c74 mmol/mol (20–42)
According to NICE guidelines (CG87, May 2009), what is the most appropriate immediate next step in management to improve his glycaemic control?

add exenatide
add pioglitazone
add sitagliptin
increase the dose of gliclazide
start insulin treatment

Answer(s): D

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