A 29-year-old woman presented with primary infertility, having had unprotected sexual intercourse for 15 months. Menarche had occurred at the age of 13.5 years. Her menstrual cycle was irregular, occurring every 20C60 days. There was no history of galactorrhoea. She denied abnormal hair growth.

On examination, her body mass index was 28.9 kg/m2 (18C25) and she had normal secondary sexual characteristics. Her visual fields were full to confrontation.

Investigations:

serum androstenedione12.8 nmol/L (0.6C8.8)

serum oestradiol205 pmol/L (200C400)

serum testosterone2.4 nmol/L (0.5C3.0)

serum sex hormone binding globulin23 nmol/L (40C137)

serum follicle-stimulating hormone4.3 U/L (2.5C10.0)

serum luteinising hormone8.5 U/L (2.5C10.0)

serum prolactin420 mU/L (<360)

hysterosalpingogrampatent fallopian tubes

partner’s semen analysisnormal sperm count and motility

What is the most appropriate first-line intervention?

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A 66-year-old woman was admitted with carpopedal spasm. During the previous week she had had 2 days of diarrhoea following treatment with ciprofloxacin for a urinary tract infection. She had long-standing rheumatoid arthritis treated with prednisolone 5 mg daily, and was also taking alendronic acid, omeprazole and furosemide.

Investigations:

serum creatinine115 ?mol/L (60C110)

serum corrected calcium1.79 mmol/L (2.20C2.60)

serum alkaline phosphatase124 U/L (45C105)

serum magnesium0.26 mmol/L (0.75C1.05)

plasma parathyroid hormone2.7 pmol/L (0.9C5.4)

Which medicine is most likely to be responsible for her metabolic derangement?

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A 48-year-old man presented with gynaecomastia. His serum oestradiol was increased and

a CT scan of adrenal glands revealed a 13-cm tumour of the left adrenal gland. Further workup showed increased secretion of 17-hydroxyprogesterone, cortisol and androstenedione. A diagnosis of adrenocortical carcinoma was suspected.

Investigations:

staging CT scan of chest and abdomenno evidence of metastasis

What is the most appropriate next step in management?

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An 18-year-old man with cystic fibrosis was referred to clinic. Over recent months his lung function had deteriorated and he had lost weight. He was being treated for a chest infection at the time of the consultation.

Investigations:

oral glucose tolerance test (75 g):

fasting plasma glucose8.2 mmol/L (3.0C6.0)

2-h plasma glucose13.5 mmol/L (<7.8)

What is the most appropriate management?

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A 55-year-old man presented with a 3-year history of increasing pain in the right hip. He had been otherwise well and was taking no medication. He was reluctant to consider any intravenous treatment as he had a phobia of needles.

Investigations:

X-ray of hipssclerotic bone in right pubis and ischium

suggestive of Paget’s disease

What is the most appropriate oral treatment?

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A 26-year-old woman was urgently referred to clinic with a 6-week history of retroorbital headaches and deteriorating vision. Her past medical history was unremarkable, although on questioning she admitted that she had recently found it increasingly difficult to cope with her busy job.

On examination, her pulse was 60 beats per minute and regular, and her blood pressure was 110/75 mmHg lying and 90/60 mmHg standing. She was pale and had dry skin. Visual acuities were reduced (6/12 right; 6/24 left), and she had a bitemporal inferior quadrantanopia.

Investigations:

serum sodium132 mmol/L (137C144)

serum potassium4.0 mmol/L (3.5C4.9)

short tetracosactide Synacthen® test (250 micrograms):

serum cortisol (30 min after tetracosactide)185 nmol/L (>550)

plasma follicle-stimulating hormone2.7 U/L

plasma luteinising hormone3.5 U/L

serum prolactin1050 mU/L (<360)

serum thyroid-stimulating hormone0.3 mU/L (0.4C5.0)

serum free T48.0 pmol/L (10.0C22.0)

serum insulin-like growth factor 14.7 nmol/L (7.5C37.3)

MR scan of brainsee image

What is the most likely diagnosis?

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A 23-year-old woman was found to have type 1 diabetes mellitus following a short history of polyuria, polydipsia and unintentional weight loss. She started taking insulin aspart before meals and insulin detemir daily.

What is the most appropriate time from diagnosis to start screening for microalbuminuria?

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A 64-year-old man presented with palpitations, fatigue and malaise. Two months previously, he had sustained an acute myocardial infarction complicated by ventricular tachycardia and cardiac arrest, and had been discharged taking amiodarone 200 mg daily.

On examination, he appeared well, his pulse was 90 beats per minute and regular, and he had mild tremor of his hands but no other abnormal signs.

Investigations:

serum thyroid-stimulating hormone6.2 mU/L (0.4C5.0)

serum free T418.2 pmol/L (10.0C22.0)

serum free T34.8 pmol/L (3.0C7.0)

What is the most appropriate next step in management?

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A 64-year-old woman presented with features of acromegaly. An MR scan showed a pituitary tumour with cavernous sinus extension. She underwent trans-sphenoidal surgery and histology of the pituitary tissue showed numerous cells immunostaining for growth hormone.

Investigations (6 months postoperatively):

MR scan of pituitaryenlarged sella, residual tumour in right cavernous sinus

serum growth hormone (day curve average)3.2 ?g/L (<2)

serum insulin-like growth factor 142.0 nmol/L (3.3C23.3)

What is the most appropriate next step in management?

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A 17-year-old Caucasian girl presented with primary amenorrhea.

On examination, her body mass index was 21 kg/m2 (18C25). Her body habitus was normal and she had appropriate breast development. There was no hirsutism or acne.

Investigations:

serum oestradiol<180 pmol/L (200C400)

serum testosterone31.7 nmol/L (0.5C3.0)

serum follicle-stimulating hormone4.0 U/L (2.5C10.0)

serum luteinising hormone6.0 U/L (2.5C10.0)

What is the most likely diagnosis?

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