QUESTION: 13

A 59-year-old man with an 8-year history of type 2 diabetes mellitus was seen in the outpatient clinic. He had worsening renal function in the absence of microalbuminuria.
On examination, his blood pressure was 175/90 mmHg. He had a femoral bruit, and absent dorsalis pedis pulses bilaterally.

Investigations:
-serum creatinine150 µmol/L (60–110)
-estimated glomerular filtration rate (MDRD)39 mL/min/1.73m2 (>60)

In addition to addressing his blood pressure, what is the most appropriate next investigation?

captopril diethylene triamine pentacaetic acid (DTPA) scan
lower limb angiography
mercaptoacetyltriglycine (MAG3) renography
MR angiography of renal arteries
renal ultrasound scan with Doppler studies

Answer(s): D

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QUESTION: 14

A 32-year-old man presented with persistent thirst. He had a past history of polydactyly, which had been corrected surgically in infancy. His family had remarked about his recent weight gain. His only concern was of blurring of vision and difficulty reading. His father and paternal grandfather had each developed type 2 diabetes mellitus when aged 41 and 56 years, respectively.
His body mass index was 34 kg/m2 (18–25). Urinalysis showed glucose 2+, ketones 1+.

Investigations:
serum sodium142 mmol/L (137–144) serum potassium3.8 mmol/L (3.5–4.9) serum chloride105 mmol/L (95–107) serum urea5.0 mmol/L (2.5–7.0) serum creatinine90 µmol/L (60–110) haemoglobin A1c91 mmol/mol (20–42) random plasma glucose11.3 mmol/L ultrasound scan of kidneysnormal

What is the most likely underlying diagnosis?

Bardet–Biedl syndrome
monogenic diabetes caused by a mutation in the glucokinase gene
monogenic diabetes caused by a mutation in the HNF-1? gene
Prader–Willi syndrome
type 2 diabetes mellitus

Answer(s): A

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QUESTION: 15

A 48-year-old woman presented with a 2-year history of weight gain, easy bruising and mood disturbance. Investigations:

fasting plasma glucose6.9 mmol/L (3.0–6.0)
low-dose dexamethasone suppression test (2 mg/day for 48 h): serum cortisol200 nmol/L (<50)
24-h urinary free cortisol (?3)670, 400 and 300 nmol (55–250) plasma adrenocorticotropic hormone (09.00 h)25.0 pmol/L (3.3–15.4) MR scan of pituitarynormal

What test is most likely to give a definitive diagnosis?

corticotropin-releasing hormone test
CT scan of chest
high-dose dexamethasone suppression text (8 mg/day for 48 h)
octreotide scan
petrosal sinus sampling

Answer(s): E

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QUESTION: 16

A 72-year-old man with a 12-year history of type 2 diabetes mellitus was found to have carcinoma of the bladder. He was taking metformin; however, this was stopped because of his deteriorating renal function. On examination, his weight was 95 kg and his body mass index was 32 kg/m2 (18–25).
Investigations:

-serum sodium143 mmol/L (137–144) serum potassium4.4 mmol/L (3.5–4.9) serum creatinine175 µmol/L (60–110)
-estimated glomerular filtration rate (MDRD)27 mL/min/1.73 m2 (>60) haemoglobin A1c64 mmol/mol (20–42)

What is the most appropriate addition to his medication?

dapagliflozin
gliclazide
liraglutide
pioglitazone
sitagliptin

Answer(s): E

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