A 46-year-old man of European descent was reviewed in the diabetes clinic. He had type 2 diabetes mellitus, which had been diagnosed 6 months previously. He had been symptom free and was a non-smoker but had a family history of cardiovascular disease. He exercised regularly and had managed to lose 8 kg.

On examination, his blood pressure was 148/76 mmHg, his weight was 76 kg and his body mass index was 24 kg/m2 (18C25).

Investigations:

urinary albumin:creatinine ratio0.6 mg/mmol (<2.5)

serum cholesterol5.6 mmol/L (<5.2)

serum HDL cholesterol0.90 mmol/L (>1.55)

fasting serum triglycerides2.20 mmol/L (0.45C1.69)

According to NICE guidelines (CG181, July 2014), what is the most appropriate management of his lipid profile?

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A 55-year-old woman presented with a 3-week history of nausea and vomiting. Her only medical complaints were frequent dyspepsia, for which she was taking indigestion tablets, and asthma for which she was taking a salbutamol inhaler as required.

On examination, there was no evidence of lymphadenopathy, her chest was clear on auscultation and abdominal examination was normal.

Investigations (before and after taking omeprazole for 3 weeks):

beforeafternormal

erythrocyte sedimentation rate (mm/1st h)44<30

serum creatinine (µmol/L)17011060C110

serum corrected calcium (mmol/L)2.852.402.20C2.60

serum phosphate (mmol/L)1.90.8C1.4

serum angiotensin-converting enzyme (U/L)8525C82

plasma parathyroid hormone (pmol/L)0.44.40.9C5.4

What is the most likely cause of the hypercalcaemia?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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A 20-year-old man presented with a 6-month history of lethargy and weakness. His brother had been found to have adrenal failure at the age of 18. He had two sisters who were well and there was no other family history of endocrine autoimmune disease.

On examination, his blood pressure was 100/60 mmHg.

Investigations:

serum sodium136 mmol/L (137C144)

serum potassium4.8 mmol/L (3.5C4.9)

short tetracosactide (Synacthen®) test (250 micrograms):

baseline serum cortisol100 nmol/L

serum cortisol (30 min after tetracosactide)250 nmol/L (>550)

anti-adrenal antibodiesnegative

What is the most important diagnosis to consider?

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