A 64-year-old man was reviewed in the diabetes clinic. He had a history of type 2 diabetes mellitus treated for 12 years. He had sustained a previous episode of acute kidney injury believed to be secondary to renal artery stenosis and exposure to an ACE inhibitor. He was being treated with metformin 500 mg three times daily and gliclazide 80 mg twice daily.

Investigations:

serum sodium143 mmol/L (137C144)

serum potassium4.4 mmol/L (3.5C4.9)

serum creatinine123 µmol/L (60C110)

estimated glomerular filtration rate (MDRD)51 mL/min/1.73 m2 (>60)

haemoglobin A1c75 mmol/mol (20C42)

He required a third drug that would not require dose adjustment if renal function were to decline in the future.

What additional medication is most appropriate?

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An 18-year-old man presented to the thyroid clinic complaining of a lump in his neck that had been present for 9 weeks. It was not painful. At the age of 12, he had developed acute lymphoblastic leukaemia and had undergone a bone marrow transplant preceded by total body irradiation and cyclophosphamide.

On examination, he was euthyroid. There was a 1.5-cm firm mass on the left side of the neck, which moved when he swallowed.

Investigations:

serum thyroid-stimulating hormone1.9 mU/L (0.4C5.0)

serum free T416.8 pmol/L (10.0C22.0)

What is the most appropriate initial course of action?

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A 16-year-old boy was referred to the diabetes clinic following the discovery of a random plasma glucose concentration of 18.0 mmol/L. His general practitioner had begun treatment with metformin. The patient had a body mass index of 35 kg/m2 (18C25). He had had problems throughout his childhood, and had been taken out of school and was educated at home by his mother. He was attending the ophthalmology clinic for visual problems.

On examination, he was obese. He had hearing aids in both ears and evidence of acanthosis nigricans. Neither parent had a history of diabetes mellitus.

What is the most likely diagnosis?

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A 26-year-old woman was recovering from diabetic ketoacidosis and had been switched to her usual basal bolus insulin regimen. Her capillary blood glucose measurements during the day were high but fasting plasma glucose was in the range 5.0C7.0 mmol/L (3.0C6.0). She was drinking and eating normally.

On examination, her pulse was 76 beats per minute and her blood pressure was 106/66 mmHg. Urinalysis showed ketones 1+.

Investigations:

serum sodium143 mmol/L (137C144)

serum potassium4.4 mmol/L (3.5C4.9)

serum bicarbonate22 mmol/L (20C28)

serum creatinine72 µmol/L (60C110)

plasma glucose 2 h after breakfast21 mmol/L

What is the most appropriate next step in management?

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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 (200C700)

serum testosterone8.6 nmol/L (9.0C35.0)

plasma follicle-stimulating hormone2.1 U/L (1.0C7.0)

plasma luteinising hormone2.4 U/L (1.0C10.0)

serum prolactin896 mU/L (<360)

serum thyroid-stimulating hormone1.4 mU/L (0.4C5.0)

MR scan of pituitarysee image

What is the most likely diagnosis?

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A 32-year-old woman, with a 22-year history of type 1 diabetes mellitus, was seen in a pre-pregnancy diabetes clinic. She was a primigravida.

On examination, she had early background retinopathy, her blood pressure was 128/68

mmHg, and her body mass index was 29.7 kg/m2 (18C25).

Investigations:

haemoglobin A1c56 mmol/mol (20C42)

urinary albumin:creatinine ratio1.2 mg/mmol (<3.5)

Over the years her haemoglobin A1c concentration had varied between 58 and 69 mmol/mol. She had impaired awareness of hypoglycaemia and experienced approximately two severe hypoglycaemic events per year. She was worried about the risk of severe congenital malformations in her baby.

To what extent will the average risk of severe congenital malformation be increased in infants born to this mother with pregestational diabetes?

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A 32-year-old woman with a recurrent history of Graves’ thyrotoxicosis was being considered for radioiodine treatment. However, she wanted to conceive again at some stage and asked how soon she could become pregnant.

After what minimum interval would it be safe for her to conceive again?

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A 26-year-old man presented urgently, complaining of muscle pains. He had been found to have heterozygous familial hypercholesterolaemia 2 years previously owing to a mutation in the PCSK9 gene. He had a strong family history of premature vascular disease. He was taking atorvastatin 80 mg daily.

Investigations:

serum creatine kinase2782 U/L (24C195)

serum cholesterol5.7 mmol/L (<5.2)

After stopping atorvastatin, his serum creatine kinase fell to within the normal range.

What is the most appropriate next step in management?

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A 26-year-old man with type 1 diabetes mellitus attended a carbohydrate-counting course to facilitate tighter glucose control. He estimated that his carbohydrate ratio was 1:10 and 1 unit correction dose reduced his glucose by 3.0 mmol/L.

He planned to eat a meal containing 50 g of carbohydrate. His pre-meal glucose was 16.0 mmol/L with a target blood glucose of 7.0 mmol/L.

What is the correct dose of bolus insulin (units) that he should administer?

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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?

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