A 50-year-old woman presents to the emergency department with sudden-onset severe headache, photophobia, and neck stiffness. She was recently started on carbimazole 40mg once daily for newly diagnosed Graves' disease 3 weeks ago. Temperature is 38.7°C, HR 116/min, BP 108/68 mmHg. She appears unwell. Full blood count shows: Hb 118 g/L, WCC 1.2 × 10⁹/L (neutrophils 0.2 × 10⁹/L), platelets 245 × 10⁹/L. What is the most critical immediate action?
Q62
A 63-year-old woman with type 2 diabetes for 11 years on metformin, gliclazide, and empagliflozin presents with recurrent genital candidiasis (4 episodes in 8 months) despite good glycaemic control (HbA1c 52 mmol/mol). She has had multiple courses of topical antifungals with temporary improvement. She has no other urogenital symptoms. BMI is 29 kg/m², blood pressure 136/82 mmHg, eGFR 72 ml/min/1.73m². Past medical history includes hypertension and previous transient ischaemic attack 3 years ago. What is the most appropriate modification to her diabetes medication regimen?
Q63
A 28-year-old woman with type 1 diabetes for 15 years is admitted with diabetic ketoacidosis. Initial results: pH 7.08, glucose 32.6 mmol/L, ketones 6.2 mmol/L, potassium 5.8 mmol/L. Standard DKA protocol is commenced with fixed-rate IV insulin infusion (FRIII) at 0.1 units/kg/hour and IV fluid resuscitation. After 6 hours, repeat blood gas shows: pH 7.28, glucose 14.2 mmol/L, ketones 2.4 mmol/L, bicarbonate 16 mmol/L, potassium 3.8 mmol/L. What represents appropriate adjustment to her insulin regimen at this point?
Q64
A 39-year-old woman is referred by her GP with suspected Graves' disease. She has palpitations, tremor, and weight loss. Examination reveals a diffuse, non-tender goitre, exophthalmos with lid retraction, and lid lag. Thyroid function shows: TSH <0.05 mU/L, free T4 42 pmol/L (10-22), free T3 18.4 pmol/L (3.5-6.5). TSH receptor antibodies are positive. She works as a primary school teacher. What is the most appropriate initial management strategy?
Q65
A 66-year-old man with type 2 diabetes for 14 years presents with progressive bilateral lower limb pain, worse at night and partially relieved by hanging legs over the bed edge. He has a 40 pack-year smoking history. Examination reveals absent foot pulses bilaterally, prolonged capillary refill time >5 seconds, reduced temperature in both feet, and a shallow ulcer on the lateral aspect of the right foot measuring 1.5cm. Ankle-brachial pressure index (ABPI) is 0.52 on the right and 0.58 on the left. What is the most appropriate next step in management?
Q66
A 31-year-old woman presents with a 3-month history of fatigue, weight gain of 6 kg, constipation, and dry skin. She is planning pregnancy. Blood tests show: TSH 14.8 mU/L (0.5-5.0), free T4 8.2 pmol/L (10-22), anti-thyroid peroxidase antibodies strongly positive. She has no previous thyroid history. What is the most appropriate initial levothyroxine dose considering her circumstances?
Q67
A 43-year-old woman with type 1 diabetes for 22 years attends for diabetic eye screening. She is asymptomatic with no visual complaints. Retinal photography shows scattered dot and blot haemorrhages, multiple cotton wool spots, venous beading in 2 quadrants, and intraretinal microvascular abnormalities (IRMA) in 1 quadrant bilaterally. There is no evidence of new vessels or macular oedema. What is the diagnosis and most appropriate management?
Q68
A 52-year-old man with type 2 diabetes for 7 years attends for his annual diabetic foot screening. He has no foot symptoms. Examination reveals normal foot structure, warm feet with palpable pulses bilaterally. 10g monofilament testing shows absent sensation at 4 out of 10 sites on the right foot and 3 out of 10 sites on the left foot. Vibration perception threshold using a neurothesiometer is 32 volts on the right and 28 volts on the left hallux. Ankle reflexes are absent bilaterally. What is his current diabetic foot risk status and appropriate management interval?
Q69
A 77-year-old woman with type 2 diabetes is admitted from a nursing home with pneumonia. She has been increasingly confused over 5 days with reduced oral intake. Observations: BP 96/54 mmHg, HR 108/min, temperature 38.2°C, GCS 13. Blood results: glucose 44.2 mmol/L, sodium 156 mmol/L, urea 28.4 mmol/L, creatinine 242 μmol/L, osmolality 368 mOsm/kg. Urine ketones negative. Which fluid regimen is most appropriate for the first 12 hours?
Q70
A 35-year-old man with type 1 diabetes for 18 years presents to the emergency department with a 2-day history of vomiting and abdominal pain. He continued his basal insulin but stopped his mealtime insulin due to poor oral intake. Blood results show: glucose 28.4 mmol/L, pH 7.21, bicarbonate 11 mmol/L, ketones 4.8 mmol/L, sodium 131 mmol/L, potassium 5.2 mmol/L, urea 9.8 mmol/L, creatinine 132 μmol/L. He is started on DKA protocol. After 4 hours of treatment, repeat potassium is 3.1 mmol/L. What is the most appropriate potassium replacement strategy?
Endocrinology & Diabetes UK Medical PG Practice Questions and MCQs
Question 61: A 50-year-old woman presents to the emergency department with sudden-onset severe headache, photophobia, and neck stiffness. She was recently started on carbimazole 40mg once daily for newly diagnosed Graves' disease 3 weeks ago. Temperature is 38.7°C, HR 116/min, BP 108/68 mmHg. She appears unwell. Full blood count shows: Hb 118 g/L, WCC 1.2 × 10⁹/L (neutrophils 0.2 × 10⁹/L), platelets 245 × 10⁹/L. What is the most critical immediate action?
A. Arrange urgent CT head and lumbar puncture to exclude meningitis
B. Stop carbimazole immediately and start broad-spectrum IV antibiotics after blood cultures (Correct Answer)
C. Give IV hydrocortisone 100mg and propranolol 40mg for impending thyroid storm
D. Arrange urgent haematology review for possible aplastic anaemia
E. Start G-CSF (granulocyte colony-stimulating factor) immediately
Explanation: ***Stop carbimazole immediately and start broad-spectrum IV antibiotics after blood cultures***- The patient presents with **fever**, **meningism**, and profound **agranulocytosis** (neutrophils 0.2 × 10⁹/L), a life-threatening side effect of **carbimazole**. This clinical picture is consistent with **neutropenic sepsis**.- The most critical immediate action is to **stop the causative drug** (carbimazole) and initiate **broad-spectrum IV antibiotics** promptly (within 1 hour) after obtaining blood cultures to treat the severe infection.*Arrange urgent CT head and lumbar puncture to exclude meningitis*- While the patient's symptoms suggest **meningism**, performing these investigations would significantly delay the administration of **life-saving antibiotics** in a critically unwell, neutropenic patient.- In suspected **neutropenic sepsis**, empirical broad-spectrum antibiotics are paramount; imaging/LP should only be considered if the patient is stable enough and if it won't delay critical treatment.*Give IV hydrocortisone 100mg and propranolol 40mg for impending thyroid storm*- Although the patient has Graves' disease and some hyperthyroid symptoms like tachycardia, the severe **neutropenia** and fever make **neutropenic sepsis** the immediate life-threatening concern, not thyroid storm.- Managing acute sepsis takes precedence; treating a potential thyroid storm without immediately addressing the profound infection risk would be inappropriate.*Arrange urgent haematology review for possible aplastic anaemia*- The blood count primarily shows severe **neutropenia** (agranulocytosis) with normal Hb and platelets, making **aplastic anaemia** (which typically involves pancytopenia) less likely than drug-induced agranulocytosis.- While a haematology review will be necessary for definitive diagnosis and management, it is not the *immediate* critical action; stabilizing the patient from sepsis is the priority.*Start G-CSF (granulocyte colony-stimulating factor) immediately*- **G-CSF** helps stimulate granulocyte production and can shorten the duration of neutropenia, but it is not a first-line emergency treatment for acute **neutropenic sepsis**.- The immediate priorities are cessation of the causative drug and aggressive **antibiotic therapy** to combat the active infection, not just to raise neutrophil counts.
Question 62: A 63-year-old woman with type 2 diabetes for 11 years on metformin, gliclazide, and empagliflozin presents with recurrent genital candidiasis (4 episodes in 8 months) despite good glycaemic control (HbA1c 52 mmol/mol). She has had multiple courses of topical antifungals with temporary improvement. She has no other urogenital symptoms. BMI is 29 kg/m², blood pressure 136/82 mmHg, eGFR 72 ml/min/1.73m². Past medical history includes hypertension and previous transient ischaemic attack 3 years ago. What is the most appropriate modification to her diabetes medication regimen?
A. Stop empagliflozin and add dulaglutide 0.75mg once weekly (Correct Answer)
B. Stop empagliflozin and increase gliclazide dose
C. Stop gliclazide and increase empagliflozin to 25mg
D. Continue all medications and add long-term prophylactic fluconazole
E. Stop empagliflozin and add pioglitazone 15mg once daily
Explanation: ***Stop empagliflozin and add dulaglutide 0.75mg once weekly***
- **SGLT2 inhibitors** like empagliflozin cause **glucosuria**, which directly promotes recurrent **genital candidiasis**; switching to a **GLP-1 receptor agonist** removes this trigger.
- **Dulaglutide** is preferred here because it provides **cardiovascular protection** (essential given her history of **TIA**) and assists with weight management without the infection risk.
*Stop empagliflozin and increase gliclazide dose*
- While stopping the SGLT2 inhibitor resolves the infection, increasing **gliclazide (a sulfonylurea)** significantly increases the risk of **hypoglycaemia**.
- This approach fails to provide the **cardiovascular benefits** required for a patient with a previous **Transient Ischaemic Attack (TIA)**.
*Stop gliclazide and increase empagliflozin to 25mg*
- Increasing the dose of **empagliflozin** would increase **urinary glucose excretion**, likely worsening the frequency and severity of the **genital candidiasis**.
- This does not address the patient's primary complaint of recurrent infections and would be clinically counterproductive.
*Continue all medications and add long-term prophylactic fluconazole*
- Prophylactic **fluconazole** is not recommended as a primary strategy to manage medication-induced infections when an effective **alternative glucose-lowering therapy** is available.
- This approach exposes the patient to unnecessary long-term drug side effects and potential **antifungal resistance** while leaving the underlying cause untreated.
*Stop empagliflozin and add pioglitazone 15mg once daily*
- **Pioglitazone** is generally avoided or used with caution in patients with a history of **stroke or TIA** due to potential concerns regarding cardiovascular complications.
- It is also associated with **weight gain** and **fluid retention**, which are undesirable given the patient's **BMI of 29 kg/m²**.
Question 63: A 28-year-old woman with type 1 diabetes for 15 years is admitted with diabetic ketoacidosis. Initial results: pH 7.08, glucose 32.6 mmol/L, ketones 6.2 mmol/L, potassium 5.8 mmol/L. Standard DKA protocol is commenced with fixed-rate IV insulin infusion (FRIII) at 0.1 units/kg/hour and IV fluid resuscitation. After 6 hours, repeat blood gas shows: pH 7.28, glucose 14.2 mmol/L, ketones 2.4 mmol/L, bicarbonate 16 mmol/L, potassium 3.8 mmol/L. What represents appropriate adjustment to her insulin regimen at this point?
A. Continue FRIII at current rate and add 10% dextrose infusion at 125ml/hour (Correct Answer)
B. Reduce FRIII to 0.05 units/kg/hour and continue 0.9% sodium chloride
C. Continue FRIII at current rate and switch to 5% dextrose instead of 0.9% saline
D. Stop FRIII and commence variable-rate IV insulin infusion targeting glucose 6-10 mmol/L
E. Increase FRIII to 0.15 units/kg/hour until ketones are <0.6 mmol/L
Explanation: ***Continue FRIII at current rate and add 10% dextrose infusion at 125ml/hour***
- The patient's **pH (7.28)** and **ketone levels (2.4 mmol/L)** indicate that **ketoacidosis** has not fully resolved, requiring the **Fixed-Rate Intravenous Insulin Infusion (FRIII)** to continue at its current rate to suppress ketogenesis.
- Her blood **glucose (14.2 mmol/L)** has fallen to a level where **10% dextrose** must be added to the IV fluids to prevent **hypoglycemia** while the therapeutic insulin dose continues to clear ketones.
*Reduce FRIII to 0.05 units/kg/hour and continue 0.9% sodium chloride*
- Reducing the **insulin rate** prematurely, before resolution of ketoacidosis (ketones <0.6 mmol/L and pH >7.3), would impede the necessary **suppression of ketone production**.
- Continuing only **0.9% sodium chloride** without adding dextrose when glucose is falling would put the patient at high risk of **hypoglycemia**.
*Continue FRIII at current rate and switch to 5% dextrose instead of 0.9% saline*
- In DKA, when blood glucose falls, **10% dextrose** is generally preferred over 5% dextrose to provide adequate glucose replacement to counteract the high insulin dose and prevent **hypoglycemia**.
- Often, dextrose is *added* to the existing fluid regimen, rather than completely replacing **0.9% saline**, which may still be required for ongoing volume resuscitation.
*Stop FRIII and commence variable-rate IV insulin infusion targeting glucose 6-10 mmol/L*
- Stopping **FRIII** is inappropriate as the patient's **ketoacidosis** is still active (ketones 2.4 mmol/L, pH 7.28), and premature cessation risks a rebound of DKA.
- A **variable-rate insulin infusion (VRIII)** is not used for acute DKA management; it is typically reserved for glucose control in stable, but nil-by-mouth, diabetic patients.
*Increase FRIII to 0.15 units/kg/hour until ketones are <0.6 mmol/L*
- The patient is responding appropriately to the current **FRIII** rate, with a significant reduction in **ketones** (from 6.2 to 2.4 mmol/L, a drop of 3.8 mmol/L over 6 hours, or ~0.63 mmol/L/hr).
- An increase in the insulin rate is only indicated if there is an inadequate response, such as a failure of ketones to fall by at least **0.5 mmol/L/hr** or glucose by **3 mmol/L/hr**.
Question 64: A 39-year-old woman is referred by her GP with suspected Graves' disease. She has palpitations, tremor, and weight loss. Examination reveals a diffuse, non-tender goitre, exophthalmos with lid retraction, and lid lag. Thyroid function shows: TSH <0.05 mU/L, free T4 42 pmol/L (10-22), free T3 18.4 pmol/L (3.5-6.5). TSH receptor antibodies are positive. She works as a primary school teacher. What is the most appropriate initial management strategy?
A. Carbimazole 40mg once daily with block and replace regimen after 4 weeks
B. Propylthiouracil 100mg three times daily
C. Carbimazole 20mg once daily with dose titration according to thyroid function (Correct Answer)
D. Radioactive iodine therapy
E. Propranolol 40mg three times daily alone, then reassess in 4 weeks
Explanation: ***Carbimazole 20mg once daily with dose titration according to thyroid function***
- **Carbimazole** is the first-line antithyroid drug for Graves' disease, and a **titration regimen** is generally preferred as it involves a lower cumulative drug dose and minimizes side effects.
- The initial dose of **Carbimazole** is adjusted every 4-8 weeks based on **thyroid function tests (TFTs)** until the patient is euthyroid.
*Carbimazole 40mg once daily with block and replace regimen after 4 weeks*
- A **block and replace** regimen involves higher doses of carbimazole followed by levothyroxine, typically reserved for patients with **unstable thyroid levels** or difficulty with frequent monitoring.
- This regimen is associated with a higher risk of **side effects** compared to the titration regimen and is not the standard first-line approach for initial management.
*Propylthiouracil 100mg three times daily*
- **Propylthiouracil (PTU)** is usually considered a second-line treatment due to the risk of severe **hepatotoxicity**, which can be fatal.
- It is primarily preferred in the **first trimester of pregnancy**, during **thyroid storm**, or if the patient is intolerant to carbimazole.
*Radioactive iodine therapy*
- Radioactive iodine is a definitive treatment but is relatively contraindicated in this patient due to active **thyroid eye disease** (exophthalmos, lid retraction, lid lag), which can be worsened by the treatment.
- As a primary school teacher, the patient's constant **contact with children** would make adherence to post-treatment radiation precautions challenging.
*Propranolol 40mg three times daily alone, then reassess in 4 weeks*
- **Propranolol** provides symptomatic relief for manifestations like **palpitations** and **tremors** by blocking beta-adrenergic receptors.
- It does not address the underlying overproduction of **thyroid hormones** and should be used as an **adjunct therapy** alongside antithyroid drugs, not as monotherapy for overt hyperthyroidism.
Question 65: A 66-year-old man with type 2 diabetes for 14 years presents with progressive bilateral lower limb pain, worse at night and partially relieved by hanging legs over the bed edge. He has a 40 pack-year smoking history. Examination reveals absent foot pulses bilaterally, prolonged capillary refill time >5 seconds, reduced temperature in both feet, and a shallow ulcer on the lateral aspect of the right foot measuring 1.5cm. Ankle-brachial pressure index (ABPI) is 0.52 on the right and 0.58 on the left. What is the most appropriate next step in management?
A. Arrange urgent vascular surgery assessment within 2 weeks
B. Start high-dose statin and antiplatelet therapy, routine podiatry referral
C. Apply compression bandaging to the ulcer and arrange outpatient vascular review
D. Request urgent CT angiography and refer to vascular multidisciplinary team within 1 week (Correct Answer)
E. Admit for IV antibiotics and surgical debridement
Explanation: ***Request urgent CT angiography and refer to vascular multidisciplinary team within 1 week***
- This patient presents with classic signs and symptoms of **critical limb ischemia (CLI)**, including **rest pain**, a non-healing **ischemic ulcer**, and severely reduced **Ankle-Brachial Pressure Index (ABPI < 0.6)**.
- According to national guidelines (e.g., **NICE**), patients with suspected CLI require **urgent assessment** by a **vascular multidisciplinary team (MDT)** within **1 week**, along with urgent **imaging (CT or MR angiography)** to identify suitable targets for revascularization.
*Arrange urgent vascular surgery assessment within 2 weeks*
- A **2-week referral timeframe** is typically appropriate for patients with **stable claudication** or less severe, non-limb-threatening peripheral arterial disease.
- However, the presence of **rest pain** and **tissue loss (ulceration)** signifies **critical limb ischemia**, which is a limb-threatening condition requiring **immediate attention** and a significantly shorter referral window (within 1 week).
*Start high-dose statin and antiplatelet therapy, routine podiatry referral*
- While **high-dose statins** and **antiplatelet therapy** are crucial for **secondary prevention** in patients with PAD and for overall cardiovascular risk reduction, they do not address the acute need for **revascularization** in CLI.
- A **routine podiatry referral** is insufficient for an active **ischemic ulcer** associated with CLI, as the priority is to restore blood flow to promote healing.
*Apply compression bandaging to the ulcer and arrange outpatient vascular review*
- **Compression bandaging** is **contraindicated** in patients with significant arterial insufficiency, especially when the **ABPI is less than 0.8** (and certainly <0.6), as it can further impair blood flow and worsen ischemia.
- This measure is typically used for **venous ulcers**, not the **arterial/ischemic ulcer** presented here. An outpatient review is too slow for CLI.
*Admit for IV antibiotics and surgical debridement*
- While infection can complicate ischemic ulcers, there is no explicit mention of systemic signs of infection (fever, spreading cellulitis, purulent discharge) requiring **immediate IV antibiotics** as the *most appropriate next step* before assessing revascularization needs.
- **Surgical debridement** of an ischemic ulcer without first ensuring adequate blood supply (**revascularization**) is ill-advised, as it can worsen tissue loss and prevent healing. Revascularization is the priority.
Question 66: A 31-year-old woman presents with a 3-month history of fatigue, weight gain of 6 kg, constipation, and dry skin. She is planning pregnancy. Blood tests show: TSH 14.8 mU/L (0.5-5.0), free T4 8.2 pmol/L (10-22), anti-thyroid peroxidase antibodies strongly positive. She has no previous thyroid history. What is the most appropriate initial levothyroxine dose considering her circumstances?
A. 25 micrograms once daily
B. 50 micrograms once daily
C. 100 micrograms once daily
D. 1.6 micrograms per kilogram body weight once daily (Correct Answer)
E. 75 micrograms once daily
Explanation: ***1.6 micrograms per kilogram body weight once daily***
- In young, healthy patients with **primary hypothyroidism**, especially those **planning pregnancy**, the goal is to achieve rapid euthyroidism using a **full replacement dose**.
- A weight-based calculation ensures the TSH is brought within the narrow target range (<2.5 mU/L) quickly to prevent **fetal neurodevelopmental** complications.
*25 micrograms once daily*
- This low starting dose is reserved for the **elderly** or patients with known **ischemic heart disease** to avoid precipitating an arrhythmia or angina.
- Using this dose in a young woman planning pregnancy would result in a dangerously slow correction of her **hypothyroid state**.
*50 micrograms once daily*
- This is a common starting dose for middle-aged adults without cardiac disease, but it is effectively a **partial replacement dose**.
- It is insufficient for a patient needing rapid normalization of thyroid function for **conception and early pregnancy**.
*100 micrograms once daily*
- While 100 mcg might be close to the final requirement for some, a **fixed dose** does not account for the patient's specific body mass and weight gain.
- Guidelines prioritize **weight-based dosing** (1.6 mcg/kg) to reach euthyroid status more accurately than generic fixed doses.
*75 micrograms once daily*
- This represents a moderate starting dose but remains an **under-replacement** for most healthy young adults with a TSH as high as 14.8 mU/L.
- It fails to meet the clinical urgency required for a patient **actively planning pregnancy** where metabolic demands will soon increase.
Question 67: A 43-year-old woman with type 1 diabetes for 22 years attends for diabetic eye screening. She is asymptomatic with no visual complaints. Retinal photography shows scattered dot and blot haemorrhages, multiple cotton wool spots, venous beading in 2 quadrants, and intraretinal microvascular abnormalities (IRMA) in 1 quadrant bilaterally. There is no evidence of new vessels or macular oedema. What is the diagnosis and most appropriate management?
A. Severe non-proliferative diabetic retinopathy - refer urgent ophthalmology within 2 weeks (Correct Answer)
B. Diabetic maculopathy - refer urgent ophthalmology within 1 week
C. Mild non-proliferative diabetic retinopathy - continue annual screening
D. Moderate non-proliferative diabetic retinopathy - refer routine ophthalmology
E. Proliferative diabetic retinopathy - refer emergency ophthalmology within 24 hours
Explanation: ***Severe non-proliferative diabetic retinopathy - refer urgent ophthalmology within 2 weeks***- This diagnosis is confirmed by the presence of **venous beading** in 2 quadrants and **intraretinal microvascular abnormalities (IRMA)** in 1 quadrant, meeting the criteria for **severe non-proliferative diabetic retinopathy (NPDR)** based on the 4-2-1 rule.- Patients with severe NPDR are at high risk of progressing to proliferative disease and require **urgent ophthalmology referral within 2 weeks** for close monitoring and consideration of treatment. *Diabetic maculopathy - refer urgent ophthalmology within 1 week*- This diagnosis requires signs like **macular oedema**, **hard exudates**, or **retinal thickening** affecting the macula, which are explicitly stated as absent in this case.- The findings of venous beading and IRMA indicate diffuse retinal ischemia and vascular changes rather than localized macular pathology.*Mild non-proliferative diabetic retinopathy - continue annual screening*- Mild NPDR is characterized by only a few **microaneurysms** and possibly some dot/blot hemorrhages, which is far less severe than the features observed.- Continuing **annual screening** would be inadequate for a patient with multiple cotton wool spots, venous beading, and IRMA, as these indicate advanced retinopathy requiring prompt intervention.*Moderate non-proliferative diabetic retinopathy - refer routine ophthalmology*- Moderate NPDR involves more extensive microaneurysms and dot/blot hemorrhages but does not meet the specific criteria of the **4-2-1 rule** for severe disease.- The presence of **venous beading** in two quadrants and **IRMA** in one quadrant places this case firmly in the severe NPDR category, making routine referral inappropriate.*Proliferative diabetic retinopathy - refer emergency ophthalmology within 24 hours*- Proliferative diabetic retinopathy (PDR) is defined by the presence of **neovascularization** (new vessels) or **vitreous hemorrhage**, which were explicitly noted as absent.- Although severe NPDR is a precursor to PDR, it does not warrant an **emergency 24-hour referral** unless there is active neovascularization or acute vision-threatening complications.
Question 68: A 52-year-old man with type 2 diabetes for 7 years attends for his annual diabetic foot screening. He has no foot symptoms. Examination reveals normal foot structure, warm feet with palpable pulses bilaterally. 10g monofilament testing shows absent sensation at 4 out of 10 sites on the right foot and 3 out of 10 sites on the left foot. Vibration perception threshold using a neurothesiometer is 32 volts on the right and 28 volts on the left hallux. Ankle reflexes are absent bilaterally. What is his current diabetic foot risk status and appropriate management interval?
A. Low risk - annual screening
B. Moderate risk - review every 3-6 months (Correct Answer)
C. High risk - review every 2-3 months
D. Active problem - weekly podiatry review
E. Low risk - screening every 2 years
Explanation: ***Moderate risk - review every 3-6 months***
- The patient exhibits clear evidence of **peripheral neuropathy**, including **absent sensation on 10g monofilament** testing at multiple sites and an elevated **vibration perception threshold (VPT >25V)**, along with absent ankle reflexes.
- The presence of neuropathy as a single risk factor, without concurrent ischemia or deformity, places the patient in the **moderate risk** category, necessitating a review every **3 to 6 months** as per diabetic foot care guidelines (e.g., NICE NG19).
*Low risk - annual screening*
- **Low risk** status is appropriate for individuals with **no clinical evidence of loss of protective sensation**, normal peripheral pulses, and absence of foot deformity.
- This patient clearly has **sensory deficits** (monofilament, VPT) and **absent ankle reflexes**, ruling out a low-risk classification.
*High risk - review every 2-3 months*
- **High risk** designation typically applies to patients with a combination of risk factors, such as **neuropathy and ischemia**, or neuropathy/ischemia with **foot deformity**, or a history of ulceration or Charcot arthropathy.
- While the patient has neuropathy, he has **palpable pulses** (no ischemia) and a **normal foot structure** (no deformity), therefore not meeting the criteria for high risk.
*Active problem - weekly podiatry review*
- An **active problem** refers to acute conditions requiring urgent intervention, such as a **diabetic foot ulcer**, **spreading infection**, or **acute Charcot neuroarthropathy**.
- This patient is asymptomatic with no visible acute issues or skin breakdown, thus an **active problem** status and weekly podiatry review are not indicated.
*Low risk - screening every 2 years*
- This option is incorrect as the patient's established **neuropathy** places him at **moderate risk**, not low risk.
- Furthermore, a **2-year screening interval** is not recommended for any diabetic foot risk category; even low-risk patients require annual screening.
Question 69: A 77-year-old woman with type 2 diabetes is admitted from a nursing home with pneumonia. She has been increasingly confused over 5 days with reduced oral intake. Observations: BP 96/54 mmHg, HR 108/min, temperature 38.2°C, GCS 13. Blood results: glucose 44.2 mmol/L, sodium 156 mmol/L, urea 28.4 mmol/L, creatinine 242 μmol/L, osmolality 368 mOsm/kg. Urine ketones negative. Which fluid regimen is most appropriate for the first 12 hours?
A. 0.9% sodium chloride 1L over 1 hour, then 1L over 2 hours, then 1L over 4 hours, then 1L over 6 hours
B. 0.45% sodium chloride 1L over 1 hour, then 1L over 2 hours, then 1L over 2 hours, then 1L over 4 hours (Correct Answer)
C. 0.9% sodium chloride 500ml over 1 hour, then 500ml over 2 hours, then 500ml over 4 hours, then 500ml over 6 hours
D. 0.45% sodium chloride 500ml over 1 hour, then 1L over 2 hours, then 1L over 4 hours
E. 0.9% sodium chloride 1L over 2 hours, then 1L over 4 hours, then 1L over 6 hours
Explanation: ***0.45% sodium chloride 1L over 1 hour, then 1L over 2 hours, then 1L over 2 hours, then 1L over 4 hours***
- The patient presents with **Hyperosmolar Hyperglycaemic State (HHS)**, evidenced by severe hyperglycaemia (44.2 mmol/L), profound hyperosmolality (368 mOsm/kg), significant dehydration (hypotension, tachycardia, elevated urea/creatinine), and absent ketosis.
- Given the severe **hypernatraemia (156 mmol/L)** and hyperosmolality, **0.45% (hypotonic) sodium chloride** is the most appropriate fluid to correct the **free water deficit** and gradually reduce serum osmolality, with an initial rapid bolus for haemodynamic support.
*0.9% sodium chloride 1L over 1 hour, then 1L over 2 hours, then 1L over 4 hours, then 1L over 6 hours*
- This regimen uses **0.9% sodium chloride**, which is **isotonic** and may exacerbate or fail to correct the patient's severe **hypernatraemia** and hyperosmolality, increasing the risk of complications.
- While 0.9% NaCl might be used for initial rapid volume expansion in profound shock, continued use for the bulk of fluid replacement in HHS with significant hypernatremia is suboptimal as it does not address the free water deficit effectively.
*0.9% sodium chloride 500ml over 1 hour, then 500ml over 2 hours, then 500ml over 4 hours, then 500ml over 6 hours*
- The total fluid volume of **2 litres over 13 hours** is significantly **insufficient** for a patient with severe dehydration and hypovolemic shock, delaying effective resuscitation.
- Similar to the previous option, utilizing **0.9% sodium chloride** for primary fluid replacement is inappropriate in the context of severe **hypernatraemia** and hyperosmolality in HHS.
*0.45% sodium chloride 500ml over 1 hour, then 1L over 2 hours, then 1L over 4 hours*
- Although it correctly specifies **0.45% sodium chloride**, the initial volume of **500ml over 1 hour** may be **too slow** to adequately address the patient's presenting **hypotension** and tachycardia, which require rapid volume expansion.
- The total volume provided is also less than what is typically recommended for severe dehydration in HHS over the initial hours.
*0.9% sodium chloride 1L over 2 hours, then 1L over 4 hours, then 1L over 6 hours*
- This fluid administration schedule is **too slow** for initial resuscitation, with the first litre given over 2 hours, which is inadequate for a patient presenting with **hypotension** and tachycardia.
- It also uses **0.9% sodium chloride**, which is not ideal for correcting the **free water deficit** in a patient with significant **hypernatraemia** and hyperosmolality.
Question 70: A 35-year-old man with type 1 diabetes for 18 years presents to the emergency department with a 2-day history of vomiting and abdominal pain. He continued his basal insulin but stopped his mealtime insulin due to poor oral intake. Blood results show: glucose 28.4 mmol/L, pH 7.21, bicarbonate 11 mmol/L, ketones 4.8 mmol/L, sodium 131 mmol/L, potassium 5.2 mmol/L, urea 9.8 mmol/L, creatinine 132 μmol/L. He is started on DKA protocol. After 4 hours of treatment, repeat potassium is 3.1 mmol/L. What is the most appropriate potassium replacement strategy?
A. Add 40 mmol potassium chloride per litre of IV fluid (Correct Answer)
B. Add 20 mmol potassium chloride per litre of IV fluid
C. Give 20 mmol potassium chloride IV bolus over 10 minutes, then add 40 mmol per litre
D. Stop insulin infusion until potassium is above 3.5 mmol/L, then add 40 mmol per litre
E. Add 60 mmol potassium chloride per litre of IV fluid
Explanation: ***Add 40 mmol potassium chloride per litre of IV fluid***
- The patient's potassium level of **3.1 mmol/L** falls within the critical range of **3.0–3.5 mmol/L** during DKA treatment.
- According to **DKA management protocols** (e.g., JBDS), when potassium is in this range, **40 mmol/L** of potassium chloride should be added to the intravenous fluids to correct the deficit and prevent further **hypokalaemia** as insulin shifts potassium **intracellularly**.
*Add 20 mmol potassium chloride per litre of IV fluid*
- This concentration is typically used when serum potassium levels are between **3.5–5.5 mmol/L** to maintain stable potassium during ongoing insulin infusion.
- At 3.1 mmol/L, adding only **20 mmol/L** would be insufficient to replenish the potassium deficit and could lead to worsening **hypokalaemia**.
*Give 20 mmol potassium chloride IV bolus over 10 minutes, then add 40 mmol per litre*
- Administering **potassium as an IV bolus** is extremely dangerous and strictly contraindicated due to the high risk of inducing fatal **cardiac arrhythmias** or **cardiac arrest**.
- Potassium must always be given as a **slow, diluted infusion** to allow for gradual cellular uptake and prevent rapid concentration changes in the bloodstream.
*Stop insulin infusion until potassium is above 3.5 mmol/L, then add 40 mmol per litre*
- Stopping insulin infusion in DKA is inappropriate as it would halt the crucial suppression of **ketogenesis** and prevent the resolution of **acidosis**, thereby worsening the patient's DKA.
- The correct approach is to **continue insulin therapy** while aggressively replacing potassium to manage both the DKA and the electrolyte imbalance simultaneously.
*Add 60 mmol potassium chloride per litre of IV fluid*
- Infusing **60 mmol/L** of potassium chloride through a peripheral intravenous line significantly increases the risk of **severe phlebitis**, local pain, and potential tissue damage.
- Most DKA guidelines and safety protocols recommend a maximum potassium concentration of **40 mmol/L** for peripheral infusions; higher concentrations typically require central venous access.
