A 62-year-old man with a history of type 2 diabetes comes to the clinic for review. 



He is currently taking a basal bolus insulin regime and metformin. He has proteinuria for which he currently takes ramipril 10 mg daily and furosemide 80 mg.

 

On examination his BP is 155/82 mmHg, pulse is 82 and regular. There is bilateral peripheral pitting oedema.



Investigations show:

[table][tr][td]Hb[/td][td]11.9 g/dL[/td][td](13.5-17.7)[/td][/tr][tr][td]WCC[/td][td]8.0 ×10[sup]9[/sup]/L[/td][td](4-11) [/td][/tr][tr][td]PLT[/td][td]198 ×10[sup]9[/sup]/L[/td][td](150-400)[/td][/tr][tr][td]Na[/td][td]138 mmol/L[/td][td](135-146)[/td][/tr][tr][td]K[/td][td]5.2 mmol/L[/td][td](3.5-5.0)[/td][/tr][tr][td]Cr[/td][td]140 µmol/L[/td][td](79-118)[/td][/tr][/table]



Twenty four hour urinary protein excretion 5.4 g. Which of the following is the therapy change most likely to reduce his proteinuria?

A 35-year-old woman presents to the endocrine clinic with a lump on the left side of her neck. She has noticed this for a few weeks and has become increasingly concerned. 



Her BP is 135/72 mmHg, pulse is 70 and regular, and there is no sweating and no tremor. She has a pea sized lump on the left side of the thyroid. 



Investigations show: 

[table][tr][td]Hb[/td][td]13.0 g/dl[/td][td](11.5-16.0)[/td][/tr][tr][td]WCC[/td][td]7.0x10[sup]9[/sup] /l[/td][td](4-11) [/td][/tr][tr][td]PLT[/td][td]178x10[sup]9[/sup] /l [/td][td](150-400)[/td][/tr][tr][td]Na[/td][td]139 mmol/l[/td][td](135-146)[/td][/tr][tr][td]K[/td][td]4.2 mmol/l [/td][td](3.5-5.0)[/td][/tr][tr][td]Cr [/td][td]112 micromol/[/td][td](79-118)[/td][/tr][tr][td]TSH[/td][td]0.8 IU/l [/td][td](0.5-4.5) [/td][/tr][/table]



Which of the following is the most appropriate next investigation?

A 17-year-old girl from a traveller family comes to the clinic for review. She is concerned that she may not be entering puberty properly as she has no secondary sexual hair development and has not begun her periods. 



There is a past history of bilateral inguinal hernias which were repaired as an infant. 



On examination she is 167 cm in height, her BP is 122/72 mmHg and BMI is 21. She has normal-looking breast development, although there is no pubic or axillary hair. 



Investigations show: 

[table][tr][td]Hb[/td][td]12.4 g/dl[/td][td](11.5-16.0)[/td][/tr][tr][td]WCC[/td][td]8.0x10[sup]9[/sup] /l[/td][td](4-11)[/td][/tr][tr][td]PLT[/td][td]180x10[sup]9[/sup] /l [/td][td](150-400)[/td][/tr][tr][td]Na[/td][td]137 mmol/l[/td][td](135-146)[/td][/tr][tr][td]K[/td][td]4.4 mmol/l[/td][td](3.5-5.0)[/td][/tr][tr][td]Cr[/td][td]110 micromol/l[/td][td](79-118)[/td][/tr][/table]



Which of the following is the most likely diagnosis?

A 62-year-old man presents to the diabetes clinic for review. His current diabetes medication includes metformin and pioglitazone. 



Past history of note includes transurethral resection of bladder tumours some three years earlier. 



On examination his BP is 142/82 mmHg, pulse is 75 and regular, his BMI is 31. Respiratory and abdominal examination is unremarkable. 

Investigations show: 

[table][tr][td]Hb[/td][td]13.4 g/dl [/td][td](13.5-17.7)[/td][/tr][tr][td]WCC[/td][td]7.1x10[sup]9[/sup] /l [/td][td](4-11) [/td][/tr][tr][td]PLT[/td][td]170x10[sup]9[/sup] /l[/td][td](150-400) [/td][/tr][tr][td]Na[/td][td]138 mmol/l[/td][td](135-146)[/td][/tr][tr][td]K[/td][td]4.9 mmol/l[/td][td](3.5-5.0)[/td][/tr][tr][td]Cr[/td][td]129 micromol/l[/td][td](79-118)[/td][/tr][tr][td]HbA1c[/td][td]7.6%[/td][td](<5.5) [/td][/tr][/table]



Which of the following is the most appropriate way to manage his diabetes? 

A 25-year-old woman presents to the Emergency department with a severe viral upper respiratory tract infection. 



She has a history of type 1 diabetes for which she takes a basal bolus insulin regime and a recent HbA1c was elevated at 8.2%. 



On examination her BP is 100/65 mmHg, pulse is 95 and regular and she has a respiratory rate of 28. Her BMI is 21. 

Investigations show: 



[table][tr][td]Hb[/td][td]12.4 g/dl[/td][td](11.5-16.0)[/td][/tr][tr][td]WCC[/td][td]9.1x10[sup]9[/sup] /l[/td][td](4-11)[/td][/tr][tr][td]PLT[/td][td]189x10[sup]9[/sup] /l[/td][td](150-400) [/td][/tr][tr][td]Na[/td][td]137 mmol/l [/td][td](135-146)[/td][/tr][tr][td]K[/td][td]3.4 mmol/l [/td][td](3.5-5.0)[/td][/tr][tr][td]Cr[/td][td]129 micromol/l [/td][td](79-118)[/td][/tr][tr][td]Bicarb[/td][td]14 mmol/l[/td][td](22-30)[/td][/tr][tr][td]pH[/td][td]7.12[/td][td](7.35-7.45)[/td][/tr][/table]



She is started on an insulin infusion and is rehydrated aggressively. Bloods are repeated two hours later. 

Repeat investigations show:



[table][tr][td]Na[/td][td]138 mmol/l[/td][td](135-146) [/td][/tr][tr][td]K[/td][td]4.0 mmol/l[/td][td](3.5-5.0)[/td][/tr][tr][td]Cr[/td][td]121 micromol/l [/td][td](79-118)[/td][/tr][tr][td]Bicarbonate[/td][td]19 mmol/l[/td][td](22-30) [/td][/tr][tr][td]pH[/td][td]7.25[/td][td](7.35-7.45)[/td][/tr][/table]



The nursing staff have become very worried as she has become unconscious. What is most likely to have occurred?