A 42-year-old motor mechanic was referred to the dermatologist with small cauliflower-like deposits on the points of his elbows. He was generally well, but on systemic enquiry, he described intermittent claudication. He had previously been hypertensive, and was taking thyroxine for primary hypothyroidism.
On examination, he was moderately obese. He had xanthelasmata on the upper eyelids of both eyes and tuberoeruptive xanthomata on both elbows, both knees and the nape of the neck.
Investigations:
serum alanine aminotransferase78 U/L (5–35)
fasting plasma glucose7.8 mmol/L (3.0–6.0)
serum urate0.48 mmol/L (0.23–0.46)
serum cholesterol13.4 mmol/L (<5.2)
serum LDL cholesterolnot measurable
serum HDL cholesterol0.90 mmol/L (>1.55)
fasting serum triglycerides9.32 mmol/L (0.45–1.69)
apolipoprotein E genotypehomozygous for apolipoprotein E2
What is the most likely diagnosis?
A 58-year-old man was referred to the endocrine clinic after a CT scan of abdomen had shown a 4.5-cm left adrenal mass, with a Hounsfield unit measurement of 11 (consistent with high lipid content). He had a 10-year history of type 2 diabetes mellitus and was taking metformin. He was also taking atenolol for hypertension.
On examination at the clinic, his blood pressure was 162/94 mmHg. He was centrally obese with a body mass index of 27 kg/m2 (18–25).
Investigations:
serum potassium3.9 mmol/L (3.5–4.9)
plasma renin activity (after 30 min upright)1.0 pmol/mL/h (3.0–4.3)
plasma aldosterone (after 4 h upright)680 pmol/L (330–830)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol164 nmol/L (<50)
24-h urinary free cortisol132 nmol (55–250)
24-h urinary catecholamines
(adrenaline and noradrenaline)normal
As the lesion was >4 cm in diameter, laparoscopic adrenalectomy was recommended.
What is the most appropriate advice to give to the surgical team about perioperative management?
A 73-year-old man with type 2 diabetes mellitus was reviewed because of deteriorating blood glucose control. He was taking metformin 850 mg twice daily.
On examination, his body mass index was 29 kg/m2 (18–25).
Investigations:
serum creatinine102 µmol/L (60–110)
haemoglobin A1c66 mmol/mol (20–42)
According to the NICE guidelines (CG87, May 2009), what would be the most appropriate additional treatment?
A 33-year-old woman was reviewed in the insulin pump clinic. She had had type 1 diabetes mellitus for 10 years. She had been treated with a continuous subcutaneous insulin infusion 3 years previously, because of frequent hypoglycaemic episodes. She had recently undergone continuous glucose monitoring (see image).
Investigations:
haemoglobin A1c43 mmol/mol (20–42)
What is the most likely cause of the blood glucose trace seen between 08.00 h and 10.00 h?
A 41-year-old man presented to his general practitioner with symptoms of palpitations, sweating and anxiety. His blood pressure was 160/102 mmHg. He was advised to take propranolol 40 mg twice daily but was admitted to hospital later that week with an episode of pulmonary oedema.
On examination at the time of admission, he was noted to be pale and sweating and he had a blood pressure of 210/124 mmHg. A phaeochromocytoma was suspected.
What is the most likely cause of the cardiovascular deterioration following administration of propranolol?
A 67-year-old woman presented to her general practitioner with a swelling in her neck. It had been present for 4–5 years and had not changed in size during that time. She was completely asymptomatic and remained well.
On examination, there was a nodular goitre and no lymphadenopathy.
Investigations:
serum thyroid-stimulating hormone1.1 mU/L (0.4–5.0)
A subsequent ultrasound scan demonstrated seven nodules bilaterally (ranging in size from 5 mm to 15 mm), which had no suspicious features.
What is the most appropriate next step in management according to British Thyroid Association 2014 Guidelines for the Management of Thyroid Cancer?
A 25-year-old woman who was 4 months pregnant presented with weight loss of 3 kg over the previous 4 weeks, associated with intermittent palpitations, tremor and feeling of warmth. She was not taking any medication.
On examination, her pulse was 100 beats per minute and regular, and her blood pressure was 130/60 mmHg. A symmetrical non-tender goitre was palpable, with an audible bruit. There was no exophthalmos.
Investigations:
serum thyroid-stimulating hormone<0.1 mU/L (0.4–5.0)
serum free T445.2 pmol/L (10.0–22.0)
serum free T322.8 pmol/L (3.0–7.0)
anti-thyroid stimulating hormone receptor
antibodies40 U/L (<7)
What is the most appropriate treatment?
A 32-year-old man presented to the emergency department after becoming acutely unwell. He had a 5-year history of type 1 diabetes mellitus and no other significant medical history.
On examination, he was apyrexial, his pulse was 120 beats per minute, his blood pressure was 96/58 mmHg and his respiratory rate was 32 breaths per minute.
Investigations:
random plasma glucose14.2 mmol/L
arterial blood gases, breathing 60% oxygen:
PO28.9 kPa (11.3–12.6)
PCO22.6 kPa (4.7–6.0)
pH7.10 (7.35–7.45)
H+79 nmol/L (35–45)
bicarbonate6.1 mmol/L (21–29)
base excess–18 mmol/L (±2)
What diagnosis is most likely to account for these results?
A 32-year-old woman presented at 34 weeks of pregnancy, after an episode of vaginal bleeding. Gestational diabetes had been diagnosed at 28 weeks and insulin was started at 29 weeks. Her pre-pregnancy body mass index was 32 kg/m2 (18–25) and there was no family history of diabetes. She was treated with betamethasone 12 mg over 2 days. She was taking 60 units of insulin subcutaneously daily (40 units prandial in three divided doses, and 20 units intermediate-acting insulin), which had been unchanged for 3 weeks.
On examination, she was apyrexial, her pulse was 96 beats per minute and her blood pressure was 124/74 mmHg. Urinalysis showed blood 1+, protein 1+, glucose 2+, ketones 3+.
Investigations:
serum sodium134 mmol/L (137–144)
serum potassium3.8 mmol/L (3.5–4.9)
serum chloride105 mmol/L (95–107)
serum urea5.0 mmol/L (2.5–7.0)
serum creatinine90 µmol/L (60–110)
random plasma glucose7.2 mmol/L
What is the most appropriate next step in management?
A 26-year-old woman presented acutely with abdominal pain.
On examination, her blood pressure was 124/72 mmHg.
Investigations:
24-h urinary dopamine10 000 nmol (<3100)
24-h urinary adrenaline43 nmol (<144)
24-h urinary noradrenaline146 nmol (<570)
CT scan of abdomen3-cm left para-aortic mass
She underwent surgical exploration and removal of the lesion, which proved to be a paraganglioma. One local lymph node, removed at the same time, was also positive for the presence of tumour.
What is the most likely underlying genetic syndrome?
A 48-year-old man was referred by his general practitioner, whose letter stated: ‘Please review this man’s blood pressure management, as he has requested a second opinion, having seen information on the internet about the need for more detailed investigation. He has been having treatment for 10 years.’
At the consultation, the patient confirmed that he was currently taking bendroflumethiazide 2.5 mg daily, atenolol 50 mg daily and perindopril 8 mg daily. His clinic blood pressure was 169/108 mmHg. Clinical examination was otherwise normal.
Investigations:
serum sodium142 mmol/L (137–144)
serum potassium3.9 mmol/L (3.5–4.9)
estimated glomerular filtration rate (MDRD)>60 mL/min/1.73 m2 (>60)
ambulant plasma renin activity0.5 pmol/mL/h (3.0–4.3)
ambulant plasma aldosterone380 pmol/L (330–830)
What is the most appropriate next step in management?
An 18-year-old man presented with delayed puberty.
On examination, he had a high arched palate. His sense of smell was intact, and he had a family history of pubertal delay. Kallman’s syndrome was suspected.
Investigations:
serum testosterone0.3 nmol/L (9.0–35.0)
serum follicle-stimulating hormone1.0 U/L (1.0–7.0)
serum luteinising hormone1.0 U/L (1.0–10.0)
bone age15 years
What further clinical finding would most strongly support the diagnosis of Kallman’s syndrome?
A 71-year-old man was brought to the emergency department in a collapsed state. He was unable to give a history. Records showed that he had ischaemic heart disease and had undergone coronary bypass grafting 2 years previously. He was taking bendroflumethiazide 2.5 mg daily and simvastatin 40 mg at bedtime.
On examination he was unwell. His pulse was 128 beats per minute and his blood pressure was 108/60 mmHg. Oxygen saturation was 96% (94–98) breathing air.
An ECG showed Q waves in leads II, III, and aVF.
Investigations:
serum sodium164 mmol/L (137–144)
serum potassium5.4 mmol/L (3.5–4.9)
serum bicarbonate19 mmol/L (20–28)
serum urea15.2 mmol/L (2.5–7.0)
serum creatinine145 µmol/L (60–110)
random plasma glucose81.2 mmol/L
What is the most appropriate fluid replacement?
A 73-year-old man with type 2 diabetes mellitus was reviewed because of borderline hypertension. He was taking metformin 1 g twice daily, gliclazide 160 mg twice daily, aspirin 75 mg daily and simvastatin 20 mg at night. He had a history of diabetic retinopathy.
On examination, his body mass index was 34 kg/m2 (18–25); his blood pressure was 146/86 mmHg. When he returned 2 months later, his blood pressure was 142/88 mmHg.
Investigations:
serum creatinine102 µmol/L (60–110)
haemoglobin A1c66 mmol/mol (20–42)
urinary albumin:creatinine ratio
(untimed specimen)7.4 mg/mmol (<2.5)
According to NICE guidelines (CG66, May 2008), what is the target for blood pressure reduction?
A 76-year-old woman with type 2 diabetes mellitus was reviewed. Treatment with thiazolidinedione was being considered, but she was worried about the effect this medication might have on the incidence of complications. She had known background retinopathy.
What complication is more likely to worsen in a patient taking a thiazolidinedione?
A 55-year-old man with mild polyuria and tiredness was seen on a renal ward. He had had a living-related kidney transplant 6 months previously. He had good graft function while being treated with prednisolone 5 mg daily, mycophenolate mofetil 1 g twice daily and tacrolimus 3 mg twice daily. He was also taking atenolol 50 mg daily and simvastatin 40 mg daily.
Investigations:
haemoglobin A1c75 mmol/mol (20–42)
random plasma glucose18.0 mmol/L
Which drug is most likely to be responsible for his diabetes of new onset?
A 36-year-old woman was referred to the endocrine clinic with abnormal thyroid function tests. She gave a 3-year history of increased sweating and anxiety following an assault and, initially, her symptoms had been attributed to post-traumatic stress disorder.
Investigations:
serum thyroid-stimulating hormone (TSH)3.1 mU/L (0.4–5.0)
serum free T429.8 pmol/L (10.0–22.0)
serum free T33.5 pmol/L (3.0–7.0)
What is the most likely interpretation of her thyroid function test results?
A 34-year-old woman presented with palpitations, heat intolerance and a slight tremor. She was 9 weeks into her first pregnancy. She had not had any morning sickness.
On examination, her pulse was 100 beats per minute. She had a small uniform goitre but no tremor and no eye signs.
Investigations:
serum thyroid-stimulating hormone<0.01 mU/L (0.4–5.0)
serum free T442.0 pmol/L (10.0–22.0)
serum free T315.0 pmol/L (3.0–7.0)
anti-thyroid-stimulating hormone receptor
antibodies14 U/L (<7)
The decision was taken to treat her Graves’ disease with propylthiouracil (PTU) rather than carbimazole.
What is the reason for this decision?
A 25-year-old woman with type 1 diabetes mellitus presented with light-headedness, nausea, thirst and vomiting of 3 days’ duration. She was fully conscious.
On examination, her pulse was 104 beats per minute and her blood pressure was 104/64 mmHg. Urinalysis showed glucose 2+, ketones 3+.
Investigations:
serum sodium150 mmol/L (137–144)
serum potassium5.5 mmol/L (3.5–4.9)
serum chloride105 mmol/L (95–107)
serum urea5.0 mmol/L (2.5–7.0)
serum creatinine90 µmol/L (60–110)
random plasma glucose20.0 mmol/L
arterial blood gases, breathing air:
PO212.4 kPa (11.3–12.6)
PCO23.4 kPa (4.7–6.0)
pH7.15 (7.35–7.45)
H+70 nmol/L (35–45)
bicarbonate6 mmol/L (21–29)
What intravenous fluid should be given over the first 30 minutes?
A 26-year-old woman was recovering from diabetic ketoacidosis and had been switched to her usual basal bolus insulin regimen. Her capillary blood glucose measurements during the day were high but fasting plasma glucose was in the range 5.0–7.0 mmol/L (3.0–6.0). She was drinking and eating normally.
On examination, her pulse was 76 beats per minute and her blood pressure was 106/66 mmHg. Urinalysis showed ketones 1+.
Investigations:
serum sodium143 mmol/L (137–144)
serum potassium4.4 mmol/L (3.5–4.9)
serum bicarbonate22 mmol/L (20–28)
serum creatinine72 µmol/L (60–110)
plasma glucose 2 h after breakfast21 mmol/L
What is the most appropriate next step in management?
A 16-year-old boy was referred to the endocrine clinic with symptoms of delayed puberty.
On examination, he had a reduced sense of smell, small-sized testes and underdeveloped secondary sexual characteristics.
Investigations:
serum testosterone3.5 nmol/L (9.0–35.0)
serum follicle-stimulating hormone1.0 U/L (1.0–7.0)
serum luteinising hormone1.5 U/L (1.0–10.0)
serum prolactin220 mU/L (<360)
MR scan of brainnormal
He asked about his future fertility.
What will be the most useful agent for him to achieve fertility?
A 78-year-old man presented with confusion, lethargy and thirst. He had hypertension treated with lisinopril 20 mg daily.
On examination, he was dehydrated. His pulse was 110 beats per minute and his blood pressure was 84/40 mmHg. Urinalysis showed ketones 1+.
Investigations:
serum sodium155 mmol/L (137–144)
serum potassium5.2 mmol/L (3.5–4.9)
serum bicarbonate17 mmol/L (20–28)
serum urea40.0 mmol/L (2.5–7.0)
serum creatinine358 µmol/L (60–110)
random plasma glucose78.0 mmol/L
He was treated with sodium chloride 0.9%. After 8 hours’ treatment, his urine output was 10 mL/h and his blood pressure was 121/50 mmHg.
Investigations (after 8 hours’ treatment):
serum sodium151 mmol/L (137–144)
serum potassium4.9 mmol/L (3.5–4.9)
serum bicarbonate18 mmol/L (20–28)
serum urea39.0 mmol/L (2.5–7.0)
serum creatinine347 µmol/L (60–110)
random plasma glucose48.0 mmol/L
What is the most appropriate next step in management?
A 62-year-old woman was referred with difficulty in swallowing and a painful, swollen neck.
On examination, her neck was tender to palpation with a small, diffuse goitre. There was no associated neck lymphadenopathy.
Investigations:
serum thyroid-stimulating hormone<0.04 mU/L (0.4–5.0)
serum free T426.0 pmol/L (10.0–22.0)
serum free T312.0 pmol/L (3.0–7.0)
What is the most likely diagnosis?
A 28-year-old woman presented to the emergency department with a 3-day history of abdominal pain. Her past medical history included intermenstrual bleeding, and she was undergoing 6-monthly renal ultrasound surveillance for a cystic lesion.
Investigations:
serum creatinine84 µmol/L (60–110)
serum corrected calcium3.20 mmol/L (2.20–2.60)
serum phosphate0.7 mmol/L (0.8–1.4)
plasma parathyroid hormone19.5 pmol/L (0.9–5.4)
What is the most likely condition underlying the clinical presentation?
A 52-year-old woman had been found to have type 2 diabetes mellitus approximately 6 months previously.
Investigations:
haemoglobin A1c50 mmol/mol (20–42)
What is the lifetime risk of her identical twin sister also developing type 2 diabetes mellitus?
A 35-year-old woman was referred with a left lower thyroid lesion. She was asymptomatic.
Examination confirmed the presence of a 2 ? 3-cm, firm, mobile, non-tender mass.
Investigations:
ultrasound-guided fine-needle aspiration biopsyThy 5
How is Thy 5 defined?
A 72-year-old man with a dense residual hemiparesis and unsafe swallow was fed via a percutaneous gastrostomy for 20 hours each day. He had type 2 diabetes mellitus that had been well controlled with metformin.
His glucose levels were uncontrolled on metformin powder at maximum dose.
According to the Joint British Diabetes Societies Guidelines (2012), what is the most appropriate next hypoglycaemic agent?
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TESTED 04 Dec 2024
