Specialty Certificate Examinations SEND Release Date

A 33-year-old woman was reviewed in the insulin pump clinic. She had had type 1 diabetes mellitus for 10 years. She had been treated with a continuous subcutaneous insulin infusion 3 years previously, because of frequent hypoglycaemic episodes. She had recently undergone continuous glucose monitoring (see image).

Investigations:

haemoglobin A1c43 mmol/mol (20–42)

What is the most likely cause of the blood glucose trace seen between 08.00 h and 10.00 h?

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 (18–25). 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?

A 24-year-old man was referred for investigation of infertility. He had been having unprotected intercourse with his partner for 18 months, but the couple had failed to conceive. He had been treated for Hodgkin’s lymphoma at the age of 17.

What is the most appropriate investigation?

A 66-year-old woman was admitted with carpopedal spasm. During the previous week she had had 2 days of diarrhoea following treatment with ciprofloxacin for a urinary tract infection. She had long-standing rheumatoid arthritis treated with prednisolone 5 mg daily, and was also taking alendronic acid, omeprazole and furosemide.

Investigations:

serum creatinine115 ?mol/L (60–110)

serum corrected calcium1.79 mmol/L (2.20–2.60)

serum alkaline phosphatase124 U/L (45–105)

serum magnesium0.26 mmol/L (0.75–1.05)

plasma parathyroid hormone2.7 pmol/L (0.9–5.4)

Which medicine is most likely to be responsible for her metabolic derangement?