1. A 60-year-old lady with dyslipidaemia, hypertension and angina has recently
been diagnosed with impaired glucose tolerance (IGT).Clinically she is obese
with a BMI of 32 kg/m2, her blood pressure is 140/80 mmHg. She is aware
that having impaired glucose tolerance is a risk factor for type 2 diabetes and
would like to discuss strategies to attenuate this risk.Which of the following
has been shown best to reduce the incidence of type 2 diabetes in individuals
with IGT?
A. Intensive lifestyle change
B. Glicazide
C. Pioglitazone 15 mg daily
D. Metformin 850mg bd
E. Acarbose 100 mg tds
Answer: A
Explanation: Key learning points
Diabetes
● Intensive lifestyle change has been shown best to reduce the incidence of
type 2 diabetes in individuals with IGT
Explanation
Both the diabetes prevention programme (DPP) and Finnish diabetes prevention
study showed a 58% reduction in incidence of type 2 diabetes after intervention
which involved intensive dietary change, increased physical activity and weight loss.
This compares with a 31% reduction in incidence when metformin was used.
Acarbose has also been shown to reduce the incidence of diabetes in combination
with lifestyle change when compared with placebo.
The ACT now study has suggested that pioglitazone reduces progression from
pre-diabetes to Type 2 diabetes, although it is not licensed for this purpose.
It was not licensed in the United Kingdom for diabetes prevention.
,The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year
results on diet and physical activity
2. A 65-year-old man is admitted with renal failure and is diagnosed with acute
tubular necrosis (ATN).
Which of the following is least likely to be the cause of acute tubular necrosis?
A. Hypovolaemia
B. Corticosteroid therapy
C. Rhabdomyolysis
D. Paracetamol poisoning
E. Hypertension
Answer: B
Explanation: Key learning points
Nephrology
● Renal failure from ATN occurs in 25% of patients with severe hepatic damage.
Explanation
Renal failure from ATN occurs in 25% of patients with severe hepatic damage.
Accelerated hypertension can cause small vessel obstruction with proliferative
endarteritis of intralobular arteries and fibrinoid necrosis of afferent arterioles and
glomerular capillary tuft.
Corticosteroid therapy has not been associated with ATN.
Other causes of ATN include:
● hypotension
● hepatic failure
● eclampsia, and
, ● drugs such as aminoglycosides, cephalosporins, cisplatin, amphotericin
3. A 16-year-old boy presents with chronic pain in his left thigh over the past few
months. He has seen his GP on four occasions and has been given paracetamol and
told that these are growing pains.
The pain has now reached the point that he refuses to mobilise beyond walking
around the house.
On examination his BP is 132/72 mmHg, pulse is 67 and regular. Clinical
examination is unremarkable apart from the fact that he appears tender over the left
femur.
Investigations show:
Haemoglobin 122 g/L (135-177
)
White cell count 8.0 ×109/L (4-11)
Platelets 178 ×109/L (150-400
)
Sodium 138 (135-146
mmol/L )
Potassium 4.3 mmollL (3.5-5)
, Creatinine 120 µmol/L (79-118)
Alanine 44 U/L (5-40)
aminotransferase
Alkaline phosphatase 780 U/L (39-117)
Which of the following is the most likely diagnosis?
A. Paget’s disease
B. Stress fracture
C. Hepatoma
D. Rickets
E. Osteosarcoma
Answer: E
Explanation: Key learning points
Radiology
● Unilateral chronic thigh pain lasting for many months, accompanied by raised
ALP, in an adolescent is consistent with a diagnosis of osteosarcoma.
Explanation
Unilateral chronic thigh pain lasting for many months, accompanied by raised
alkaline phosphatase, in an adolescent is consistent with a diagnosis of
osteosarcoma. Plain film of the affected bone, accompanied by a CT scan of the
area and the chest are the investigations of choice.
Hepatoma in the presence of normal transaminases is extremely unlikely.
Paget's disease, whilst associated with a raised alkaline phosphatase, does not
usually occur in this age group.
Rickets would not be expected to occur in a single bone, and a stress fracture would
not present with many months of pain.
been diagnosed with impaired glucose tolerance (IGT).Clinically she is obese
with a BMI of 32 kg/m2, her blood pressure is 140/80 mmHg. She is aware
that having impaired glucose tolerance is a risk factor for type 2 diabetes and
would like to discuss strategies to attenuate this risk.Which of the following
has been shown best to reduce the incidence of type 2 diabetes in individuals
with IGT?
A. Intensive lifestyle change
B. Glicazide
C. Pioglitazone 15 mg daily
D. Metformin 850mg bd
E. Acarbose 100 mg tds
Answer: A
Explanation: Key learning points
Diabetes
● Intensive lifestyle change has been shown best to reduce the incidence of
type 2 diabetes in individuals with IGT
Explanation
Both the diabetes prevention programme (DPP) and Finnish diabetes prevention
study showed a 58% reduction in incidence of type 2 diabetes after intervention
which involved intensive dietary change, increased physical activity and weight loss.
This compares with a 31% reduction in incidence when metformin was used.
Acarbose has also been shown to reduce the incidence of diabetes in combination
with lifestyle change when compared with placebo.
The ACT now study has suggested that pioglitazone reduces progression from
pre-diabetes to Type 2 diabetes, although it is not licensed for this purpose.
It was not licensed in the United Kingdom for diabetes prevention.
,The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year
results on diet and physical activity
2. A 65-year-old man is admitted with renal failure and is diagnosed with acute
tubular necrosis (ATN).
Which of the following is least likely to be the cause of acute tubular necrosis?
A. Hypovolaemia
B. Corticosteroid therapy
C. Rhabdomyolysis
D. Paracetamol poisoning
E. Hypertension
Answer: B
Explanation: Key learning points
Nephrology
● Renal failure from ATN occurs in 25% of patients with severe hepatic damage.
Explanation
Renal failure from ATN occurs in 25% of patients with severe hepatic damage.
Accelerated hypertension can cause small vessel obstruction with proliferative
endarteritis of intralobular arteries and fibrinoid necrosis of afferent arterioles and
glomerular capillary tuft.
Corticosteroid therapy has not been associated with ATN.
Other causes of ATN include:
● hypotension
● hepatic failure
● eclampsia, and
, ● drugs such as aminoglycosides, cephalosporins, cisplatin, amphotericin
3. A 16-year-old boy presents with chronic pain in his left thigh over the past few
months. He has seen his GP on four occasions and has been given paracetamol and
told that these are growing pains.
The pain has now reached the point that he refuses to mobilise beyond walking
around the house.
On examination his BP is 132/72 mmHg, pulse is 67 and regular. Clinical
examination is unremarkable apart from the fact that he appears tender over the left
femur.
Investigations show:
Haemoglobin 122 g/L (135-177
)
White cell count 8.0 ×109/L (4-11)
Platelets 178 ×109/L (150-400
)
Sodium 138 (135-146
mmol/L )
Potassium 4.3 mmollL (3.5-5)
, Creatinine 120 µmol/L (79-118)
Alanine 44 U/L (5-40)
aminotransferase
Alkaline phosphatase 780 U/L (39-117)
Which of the following is the most likely diagnosis?
A. Paget’s disease
B. Stress fracture
C. Hepatoma
D. Rickets
E. Osteosarcoma
Answer: E
Explanation: Key learning points
Radiology
● Unilateral chronic thigh pain lasting for many months, accompanied by raised
ALP, in an adolescent is consistent with a diagnosis of osteosarcoma.
Explanation
Unilateral chronic thigh pain lasting for many months, accompanied by raised
alkaline phosphatase, in an adolescent is consistent with a diagnosis of
osteosarcoma. Plain film of the affected bone, accompanied by a CT scan of the
area and the chest are the investigations of choice.
Hepatoma in the presence of normal transaminases is extremely unlikely.
Paget's disease, whilst associated with a raised alkaline phosphatase, does not
usually occur in this age group.
Rickets would not be expected to occur in a single bone, and a stress fracture would
not present with many months of pain.
