20. Iwona is a 30-year-old woman with known type 1 diabetes for 12 years.

She visits her GP

complaining of tiredness and weight gain. Her HbA1c levels over the past 7 years have ranged between
6.4 and 7.1%, but her most recent test showed an HbA1c of 8.3%. Iwona tells you that her diet has not
changed but she is undertaking less exercise due to extreme fatigue. The dose of her insulin has not
changed and she continues in her current job as a teacher and has no family problems or social issues of
note. On further questioning, Iwona tells you that her skin is getting very dry, is feeling constantly cold
and her hair is becoming coarse and brittle. Also, she has had recent problems with menstrual
irregularities and has been constipated. On examination, Iwona indeed has dry skin and inspection of
her face reveals periorbital puffi ness. Her pulse is slow at 52 beats/min regular and she has slow
relaxing refl exes. Neck palpation reveals no goitre.