1. According to current National Institute of Clinical Excellence (NICE) guidance, metformin should be stopped (due to lactic acidosis) when the estimated glomerular filtration rate falls below what level? Select ONE option only

A. 25 ml/min/1.73 m2
B. 30 ml/min/1.73 m2
C. 40 ml/min/1.73 m2
D. 45 ml/min/1.73 m2
E. 50 ml/min/1.73 m2

Answer:: B

See NICE guideline 66 (May 2008) Type 2 Ddiabetes: the management of type 2 diabetes.

2. A 49-year-old man attends for a repeat prescription of insulin, which has recently been started by his consultant diabetologist. His latest HbA1c is 10.2%. He currently works as a taxi driver.What is the SINGLE MOST appropriate advice to give to this patient regarding his work?

A. He can continue driving without any restrictions
B. He should inform the Driver and Vehicle Licensing Agency (DVLA) and can then continue driving without any restrictions
C. He should inform the DVLA and await further assessment from one of their medical advisors
D. He should inform the DVLA and can continue driving once his insulin dose is stable
E. He should inform the DVLA and must stop driving immediately

Answer: E

The DVLA recognizses two groups of licence holder – —Group 1 (for car and motorcycle drivers) and Group 2 (for taxi, lorry and bus drivers).Patients with insulin-treated diabetes and a Group 1 licence must be able to recognizse the warning symptoms of hypoglycaemia before being granted either a one1, two 2 or three 3 year licence.Patients with insulin-treated diabetes and a Group 2 licence are barred by law from driving.www.dft.gov.uk/dvla/medical.

3. A 74-year-old woman with type 2 diabetes presents with a swelling on her left thigh for the last 3 months. She was started on insulin 6 months ago and always uses her left thigh as an insulin injection site. On examination, a small soft mass is felt underneath the skin. There is no overlying erythema.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Acanthosis nigricans
B. Cellulitis
C. Insulinoma
D. Lipid hypertrophy
E. Necrobiosis lipoidica

Answer: D

The most likely diagnosis is lipid hypertrophy. The history that this patient has not been rotating injection sites. All patients starting insulin are advised to vary the site of injection to reduce the risk of this complication.Cellulitis is more common in those with diabetes, although there are no features to suggest it as a diagnosis here.An insulinoma is an insulin-secreting pancreatic tumour.Acanthosis nigricans is a rare skin condition which can be associated with insulin resistance and diabetes. It causes papillomatous hyperplasia of the dermis with hyperpigmentation – —commonly in the axilla, groin and neck creases.Necrobiosis lipoidica is a skin condition closely associated with diabetes. Initially, there are dusky red nodules on the shin which later become flat, irregular and yellow–-brown. Small-vessel damage in the dermis is thought to be implicated in its aetiology. It is more common in young and middle-aged women.