A 64-year-old man was referred to the foot clinic. He had tripped over his cat 1 week previously and had complained of an ache in his left foot since then. He had a 12-year history of type 2 diabetes mellitus and hypertension. He was taking metformin, gliclazide, pioglitazone, bendroflumethiazide, ramipril, simvastatin and aspirin.

On examination, his blood pressure was 154/88 mmHg. Foot examination showed absent vibration perception to his ankle. The dorsalis pedis and posterior tibial pulses were easily palpable on both feet.

Investigations:

serum urea12.6 mmol/L (2.5C7.0)

serum creatinine166 µmol/L (60C110)

haemoglobin A1c79 mmol/mol (20C42)

urinary albumin:creatinine ratio8.7 mg/mmol (<2.5)

X-ray of left footsee image

What is the most appropriate initial management for this deformity?

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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 (0.4C5.0)

serum free T442.0 pmol/L (10.0C22.0)

serum free T315.0 pmol/L (3.0C7.0)

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?

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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 (18C25).

Investigations:

serum potassium3.9 mmol/L (3.5C4.9)

plasma renin activity (after 30 min upright)1.0 pmol/mL/h (3.0C4.3)

plasma aldosterone (after 4 h upright)680 pmol/L (330C830)

overnight dexamethasone suppression test (after 1 mg dexamethasone):

serum cortisol164 nmol/L (<50)

24-h urinary free cortisol132 nmol (55C250)

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?

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A 16-year-old boy was referred with concern about delayed puberty. His stature had been short as a child. He reported an increase in height at the age of 13, and had begun to develop pubic hair at the age of 14. He reported no further growth or development in the past year. His father recalled going through puberty at the age of 13.

On examination, his height was 1.60 m (between 0.4th and 2nd centile), weight was 56.4 kg (between 9th and 25th centile), genital development was Tanner stage 2 and testicular volume was 8 mL bilaterally. Pubic hair was Tanner stage 2, with no evidence of androgenic axillary hair. Bone age at the left wrist was 13.5 years.

Investigations:

serum testosterone2.9 nmol/L (9.0C35.0)

Which feature in his clinical presentation most strongly suggests a diagnosis other than constitutional delay?

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A pregnant 36-year-old woman presented to the diabetes outpatient clinic. She had type 2 diabetes mellitus treated with diet, lifestyle changes and metformin 500 mg twice daily.

On examination, her blood pressure was 128/84 mmHg.

Investigations:

haemoglobin A1c47 mmol/mol (20C42)

urinary albumin: creatinine ratio1.6 mg/mmol (<3.5)

Which is the best agent to reduce the risk of pre-eclampsia in this patient?

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A 77-year-old woman presented with acute severe pain in the mid-thoracic spine after lifting a heavy bag of shopping. She had reported losing 6 cm in height over the preceding 5 years.

On examination, she was of slight build and experienced difficulty rising from a chair. There was tenderness in the region of T9/10.

Investigations:

plain thoracic X-ray of spinewedge fracture of T10

DXA scanT score C2.7 at L1CL4 and C2.3 at

the left total hip

What is the best estimate for the proportion of vertebral fractures that present clinically with back pain, as seen in this patient?

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A 61-year-old woman was referred to the blood pressure clinic because of refractory hypertension. One year previously, her blood pressure, urea and electrolytes had been normal. Her current therapy included verapamil modified-release 240 mg daily and doxazosin 16 mg daily.

On examination, she was 1.63 m tall and weighed 90 kg with an elevated waist to hip ratio.

Her blood pressure was 182/94 mmHg supine.

Investigations:

serum sodium137 mmol/L (137C144)

serum potassium2.8 mmol/L (3.5C4.9)

serum creatinine79 µmol/L (60C110)

plasma renin activity (after 30 min supine)<1.1 pmol/mL/h (1.1C2.7)

plasma aldosterone (after 30 min supine)<135 pmol/L (135C400)

What is the most appropriate investigation?

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A 36-year-old man of South Asian origin presented acutely with a widespread pruritic rash involving the extensor surfaces of the limbs.

On examination, he was moderately obese with a body mass index of 33 kg/m2 (18C25), and the rash was erythematous, with multiple small papules with yellow centres.

Investigations:

fasting plasma glucose11.0 mmol/L (3.0C6.0)

haemoglobin A1c109 mmol/mol (20C42)

serum cholesterol8.0 mmol/L (<5.2)

serum HDL cholesterol0.80 mmol/L (>1.55)

fasting serum triglycerides31.00 mmol/L (0.45C1.69)

What is the most likely diagnosis?

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A 37-year-old woman presented with a 2-year history of increasingly frequent flushing episodes. She described alternating loose bowel motions and constipation. She had also noted menstrual irregularity. She had no respiratory symptoms. She denied headache or chest pain, but complained of palpitations.

On examination, she appeared well. Her blood pressure was 128/82 mmHg.

Investigations:

serum thyroid-stimulating hormone0.8 mU/L (0.4C5.0)

What is the most appropriate next investigation?

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A 26-year-old woman presented with recurrent Graves’ disease. After discussing the treatment options, she chose radioiodine.

What dose of radioiodine is most appropriate in uncomplicated Graves’ disease?

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