A 67-year-old woman with type 2 diabetes mellitus presented to the foot clinic with an ulcer at the plantar aspect of her fifth left toe. The ulcer probed to bone but there were no signs of inflammation. There had been a little improvement during 6 weeks of podiatric treatment, but there was some concern about possible osteomyelitis. An X-ray of toe 4 weeks previously had been normal.
What is the most appropriate next investigation?

• A. triple phase isotope bone scan
• B. plain X-ray of foot
• C. CT scan of foot
• D. white cell labelled scan
• E. MR scan of foot

A 26-year-old woman with type 1 diabetes mellitus was seen in the antenatal diabetes clinic and was 8 weeks pregnant. The father of her child also had type 1 diabetes mellitus. They were concerned that their child might develop type 1 diabetes mellitus.
What is the likelihood of the child developing type 1 diabetes mellitus?

• A. 25-40%
• B. 55-75%
• C. 5-10%
• D. 85-100%
• E. 0.1-1%

A 62-year-old man with newly diagnosed type 2 diabetes mellitus presented with weight loss and anaemia.
On examination, the only abnormalities were evidence of recent weight loss and a red-brown rash on his lower limbs. Urinalysis showed glucose 3+.
Investigations:
serum total bilirubin19 umol/L (1-22) serum aspartate aminotransferase26 U/L (1-31) serum alkaline phosphatase98 U/L (45-105) serum gamma glutamyl transferase26 U/L (<50)
plasma gastrin21 pmol/L (<55)
plasma glucagon246 pmol/L (<50)
plasma pancreatic polypeptide158 pmol/L (<300)
plasma vasoactive intestinal polypeptide12 pmol/L (<30)
chromogranin A214 U/L (<40)
serum thyroid-stimulating hormone4.9 mU/L (0.4-5.0)
serum free T49.1 pmol/L (10.0-22.0)
CT scan of abdomen2-cm mass in the tail of the pancreas
What is the most likely explanation for the rash?

• A. necrolytic migratory erythema
• B. cutaneous metastasis
• C. necrobiosis lipoidica diabeticorum
• D. acrodermatitis enteropathica
• E. pellagra

A 17-year-old girl was referred to the outpatient clinic with irritability, weight loss and difficulty sleeping. At the age of 4, she had presented with rapid growth, breast development and vaginal bleeding. The results of a gonadotropin-releasing hormone (GnRH) stimulation test performed at that time are given below.
serum oestradiolplasma FSHplasma LH
(200-400 pmol/L)(2.5-10.0 U/L)(2.5-10.0 U/L)
0 min365<0.7<0.5
30 min-<0.7<0.5
60 min-<0.7<0.5
She had been treated with GnRH analogue until the age of 11 and puberty had then progressed normally.
On examination, she was found to be tremulous, tachycardic and hyper-reflexic. Several large, irregular cafe-au-lait spots were found.
Investigations:
serum thyroid-stimulating hormone<0.05 mU/L (0.4-5.0)
serum free T436.0 pmol/L (10.0-22.0)
What is the most likely diagnosis?

• A. Carney's complex
• B. multiple endocrine neoplasia type 2
• C. Cowden's syndrome
• D. neurofibromatosis type 1
• E. McCune-Albright syndrome

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 (24-195)
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?

• A. start ezetimibe 10 mg
• B. start fluvastatin 40 mg
• C. start fenofibrate 100 mg
• D. restart atorvastatin 10 mg
• E. restart atorvastatin 40 mg