QUESTION: 33

A 17-year-old boy with type 1 diabetes mellitus was admitted with diabetic ketoacidosis precipitated by a recent viral illness.
Investigations on admission:

-random plasma glucose15.0 mmol/L arterial blood gases, breathing air:
-pH7.07 (7.35–7.45)
-H+85 nmol/L (35–45)
-Investigations after initial treatment with fluids, insulin and potassium 7 h after admission: random plasma glucose4.0 mmol/L serum bicarbonate10 mmol/L (20–28)

At this stage, he was being given infusions of insulin (1 U/h) and glucose 5% (100 mL/h). What is the most appropriate next step in management?

continue current regimen
continue current regimen but encourage oral carbohydrate intake
continue insulin infusion and change glucose to a higher concentration
give intravenous sodium bicarbonate
stop insulin infusion if glucose falls any further, then repeat plasma glucose in 15 min

Answer(s): C

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QUESTION: 34

A 56-year-old man was referred urgently by an ophthalmologist after presenting with a 6-month history of deteriorating vision. The patient had a 40 pack-year smoking history. Before his vision problem, he had never visited his general practitioner.

Investigations:
-serum cortisol (09.00 h)389 nmol/L (200–700) serum testosterone8.6 nmol/L (9.0–35.0)
-plasma follicle-stimulating hormone2.1 U/L (1.0–7.0) plasma luteinising hormone2.4 U/L (1.0–10.0)
-serum prolactin896 mU/L (<360)
-serum thyroid-stimulating hormone1.4 mU/L (0.4–5.0) MR scan of pituitarysee image

What is the most likely diagnosis?

craniopharyngioma
meningioma
non-functioning adenoma
prolactinoma
Rathke’s cyst

Answer(s): B

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QUESTION: 35

An 18-year-old man presented with delayed puberty.
On examination, he had a high arched palate. His sense of smell was intact, and he had a family history of pubertal delay. Kallman’s syndrome was suspected.

Investigations:
-serum testosterone0.3 nmol/L (9.0–35.0)
-serum follicle-stimulating hormone1.0 U/L (1.0–7.0) serum luteinising hormone1.0 U/L (1.0–10.0)
-bone age15 years

What further clinical finding would most strongly support the diagnosis of Kallman’s syndrome?

bimanual synkinesia (mirror movements)
eunuchoid habitus
night blindness
short stature
testes 6 mL bilaterally

Answer(s): A

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QUESTION: 36

A 17-year-old girl with Turner’s syndrome attended the clinic for review. She had been treated with growth hormone therapy for the previous 7 years, and had now reached her final adult height.
What is the most appropriate next step in management?

assess her bone density by DXA scan and continue growth hormone if bone mineral density is less than mean for age
continue growth hormone until 25 years old then reassess
start to reduce growth hormone therapy with a view to discontinuing in 2 years’ time
stop growth hormone therapy
withdraw growth hormone therapy for 3 months and evaluate growth hormone secretion

Answer(s): D

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