A 63-year-old woman visits her doctor with complaints of hair loss, weight gain, and feeling lethargic. She reports no other health issues. The doctor orders thyroid function tests, and the results are:
– Thyroid stimulating hormone (TSH) 0.3 mu/l
– Free T4 8 pmol/l
What test is most likely to provide a definitive diagnosis?
A 50-year-old man presents to the endocrinology clinic with abnormal blood test results. His GP had ordered thyroid function tests due to concerns about hair loss. The patient denies any other symptoms such as weight changes, temperature sensitivity, or mood changes. The GP suspected male-pattern hair loss but ordered the blood test anyway. The patient’s full blood count, renal function, and iron levels were all normal, but his TSH was 12mU/l and his free T4 was 12 pmol/l. On examination, there is no evidence of goitre.
What is the most appropriate management plan for this patient?
A 26-year-old woman presents to the emergency department after being found unwell by friends. She has a history of vomiting and diarrhea for the past three days and her housemate reports that she has not been taking her regular insulin. The patient is disorientated and unable to provide any history. On examination, she is dehydrated with abdominal tenderness but no focal peritonism. Her vital signs show a blood pressure of 86/57 mmHg, heart rate of 127 beats per minute, respiratory rate of 28 per minute, and O2 saturations of 100% on room air. Her fingerpick blood glucose is 38.2 mmol/L and blood ketones are 8.7 mmol/L. Arterial blood gas shows a pH of 7.05, PaCO2 of 15 mmHg, PaO2 of 99 mmHg, bicarbonate of 12.3 mmol/L, chloride of 111 mmol/L, and lactate of 7.5 mmol/L. What is the appropriate strategy for intravenous insulin treatment in this patient?
A 25-year-old woman with a history of anorexia presents to her primary care physician with vomiting and stomach discomfort.
Investigations:
Urea 18 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 90 µmol/l 50–120 µmol/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Corrected calcium (Ca2+) 3.5 mmol/l 2.2–2.6 mmol/l
Plasma parathyroid hormone (PTH) 8.5 pmol/l 0.9–5.4 mmol/l
Initiation of fluid resuscitation with 0.9% sodium chloride is commenced.
What would be the subsequent step in management after fluid resuscitation?
A 45-year-old male presents with a six-month history of impotence and reduced libido. He has been married for 20 years and has two children. He smokes five cigarettes per day and drinks approximately 12 units of alcohol weekly.
On examination, he appears obese but otherwise phenotypically normal with normal secondary sexual characteristics. His blood tests show normal electrolytes, liver function, and fasting glucose levels. His T4 and TSH levels are within normal range, as is his prolactin level.
However, his testosterone level is low at 6.6 nmol/L (normal range is 9-30), while his LH and FSH levels are elevated at 23.7 mU/L (normal range is 4-8) and 18.1 mU/L (normal range is 4-10), respectively.
Which additional investigation would you choose to further evaluate this patient’s condition?
A 57-year-old unemployed man presents to hospital with complaints of weight loss and weakness. He has difficulty climbing stairs and rising from his armchair at home. He lives alone and drinks 50 units of alcohol per week while smoking 20 cigarettes daily for 40 years. His blood pressure is 197/98 mmHg. Upon investigation, his Hb is 99 g/L, WBC is 9.8 ×109/L, platelets are 350 ×109/L, sodium is 145 mmol/L, potassium is 2.8 mmol/L, urea is 4.1 mmol/L, creatinine is 120 µmol/L, bicarbonate is 35 mmol/L, and glucose is 12.9 mmol/L. An arterial blood gas shows a pH of 7.26. Which investigation would be most useful in determining the cause of his illness?
A 50-year-old female presents with light-headedness and abdominal pain. She has a medical history of asthma and takes regular beclometasone and as required salbutamol. On examination, her blood pressure is 95/75 mmHg and heart rate 115 beats per minute.
Blood results show:
– Hb 135 g/l
– Platelets 352 * 109/l
– WBC 14.2 * 109/l
– Neuts 10.3 * 109/l
– Lymphs 2.2 * 109/l
– Na+ 129 mmol/l
– K+ 5.2 mmol/l
– Urea 10.2 mmol/l
– Creatinine 115 µmol/l
– CRP 8 mg/l
A short Synacthen test is performed:
Time (minutes) 0 30 60
Cortisol (nmol/l) 150 165 212
A long Synacthen test is then performed:
Time (hours) 1 2 8 24
Cortisol (nmol/l) 202 420 820 1626
What is the most likely cause of her symptoms and abnormal test results?
A 49-year-old woman presents with a 2-month history of fatigue, anorexia and nausea. She has also noticed some darkening of the skin on her hands. Prior to this, she was fit and well, with no significant past medical history. She has a strong family history of Graves’ disease.
On examination, there is some evidence of wasting of the face, and noticeable hyperpigmentation of the palmar creases. Her blood pressure is 105/75 mmHg. Blood tests are taken:
Na+ 134 mmol/L (135 – 145)
K+ 5.3 mmol/L (3.5 – 5.0)
Urea 6.8 mmol/L (2.0 – 7.0)
Creatinine 76 µmol/L (55 – 120)
Calcium 2.43 mmol/L (2.1-2.6)
Thyroid stimulating hormone (TSH) 1.2 mU/L (0.5-5.5)
Free thyroxine (T4) 13.3 pmol/L (9.0 – 18)
What subsequent test can be conducted to differentiate between a primary and secondary cause of the likely diagnosis?
A 35-year-old alcoholic presents with abdominal pain and vomiting. His amylase is 1200 U/l and he is being treated for acute pancreatitis. You are called to see him as the nursing staff report the patient is becoming restless. He complains of numbness around his mouth and appears to be in some discomfort.
Your foundation year 2 colleague notes this morning’s blood results:
Adjusted calcium 1.8 mmol/l
Na+ 136 mmol/l
K+ 3.7 mmol/l
Urea 6.9 mmol/l
Creatinine 81 µmol/l
What is the next step in management?
A 35-year-old woman presents to the hypertension clinic with difficult-to-control hypertension. She reports occasional aches and pains that mainly affect her arms and legs, as well as an increase in urinary frequency and urgency. Her blood pressure reading at the clinic is 175/95 mmHg. She is currently being treated with amlodipine and lisinopril for hypertension. Blood tests taken prior to her visit show normal electrolyte levels and mildly elevated creatinine. An aldosterone and renin test reveals an increased aldosterone-to-renin ratio, and a CT abdomen confirms bilateral adrenal hyperplasia. What is the most appropriate management for this patient?