QUESTION: 5

A 34-year-old woman with a 21-year history of type 1 diabetes mellitus had started treatment with subcutaneous insulin pump therapy 18 months previously. Her haemoglobin A1c before starting pump therapy was 77 mmol/mol (20–42) and she had experienced severe hypoglycaemic events without warning symptoms over the previous 4 years.

At review in clinic, she reported continuing episodes of severe hypoglycaemia without warning symptoms despite regular monitoring and advice from her insulin pump nurse specialist.
On examination, her blood pressure was 134/80 mmHg and fundoscopy revealed moderate background diabetic retinopathy. Examination of the feet revealed strong, palpable pedal pulses and early evidence of sensory neuropathy.

Investigations:
-estimated glomerular filtration rate (MDRD)24 mL/min/1.73 m2 (>60) haemoglobin A1c56 mmol/mol (20–42)
-24-h urinary total protein2.3 g (<0.2)

What is the most appropriate next step in management?

change to intensified subcutaneous insulin injections
refer for allogeneic pancreas transplantation
refer for allogeneic pancreatic islet cell transplantation
refer for combined pancreas and kidney transplantation
refer for continuous glucose monitoring

Answer(s): D

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QUESTION: 6

A 42-year-old woman, with type 1 diabetes mellitus of 22 years’ duration, attended for annual review. She was using biphasic insulin twice daily and taking aspirin 75 mg, simvastatin 40 mg and ramipril 10 mg daily.
On examination, her blood pressure was 164/87 mmHg. Investigations:

-serum potassium5.9 mmol/L (3.5–4.9) serum creatinine197 µmol/L (60–110)
-estimated glomerular filtration rate (MDRD)26 mL/min/1.73 m2 (>60) haemoglobin A1c72 mmol/mol (20–42)
-urinary albumin:creatinine ratio27.0 mg/mmol (<3.5) urine culturenegative

What is the most important next step in management?

add aliskiren
add furosemide
change to intensive insulin regimen
check bicarbonate
refer to a nephrologist

Answer(s): E

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QUESTION: 7

A 55-year-old man with type 2 diabetes mellitus presented with foot swelling and discomfort. He had a peripheral sensory neuropathy attributed to diabetes mellitus. A midfoot Charcot’s arthropathy was suspected, and a plain X-ray was arranged (see image).

Which is the talonavicular joint?

1
2
3
4
5

Answer(s): B

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QUESTION: 8

A 54-year-old woman attended clinic for routine follow-up. She had Cushing’s syndrome secondary to ectopic adrenocorticotropic hormone syndrome with no primary source identified.

She had declined bilateral adrenalectomy. Routine medication included metyrapone 500 mg three times daily, ketoconazole 200 mg once daily and hydrocortisone 10 mg in the morning and 5 mg in the evening.

Metyrapone inhibits the action of which enzyme in steroidogenesis?

3?-hydroxysteroid dehydrogenase
5?-reductase
11?-hydroxylase
17?-hydroxylase
21-hydroxylase

Answer(s): C

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