A 29-year-old woman comes to you with a complaint of worsening coordination over the past three months. Upon examination, her blood pressure is 124/74 mmHg. The only notable findings are right-sided dysdiadokinesis with nystagmus and a tendency to fall to the right. Additionally, you observe several café-au-lait spots. Which of the following potential causes would NOT account for her lack of coordination?
A 67-year-old woman presents with a two-month history of increasing thirst, fatigue, and weight loss. She had breast cancer ten years ago and underwent a mastectomy, and has been taking tamoxifen since then. She also has a three-year history of hypertension and takes bendroflumethiazide 2.5 mg daily. On examination, her blood pressure is 162/90 mmHg, but no other abnormalities are found. She takes a large number of vitamins every day. Her general practitioner orders a series of biochemical tests, which reveal hypercalcemia. What is the most likely cause of her elevated calcium levels?
A 60-year-old female presents with a three month history of generalised aches and pains.
These problems began rather gradually and she has noticed less energy of late. She has otherwise been in good health but has a five year history of hypertension for which she is treated with bendroflumethiazide 2.5 mg daily and more recently she has received lisinopril 5 mg daily. She has received regular blood pressure checks at her GP’s clinic. Over the last one year she has also been taking vitamin D supplements as she has been concerned regarding osteoporosis. She stopped taking female HRT approximately five years ago.
Of relevance in her family history was a strong maternal history of osteoporosis. Her mother had a fractured neck of femur at the age of 70 and her maternal aunts had problems with osteoporosis. She is a smoker of 15 pack years having stopped smoking five years ago. She drinks approximately 12 units of alcohol weekly.
On examination she is slightly built with a BMI of 22.2 kg/m2 and has a blood pressure of 152/84 mmHg. No specific abnormalities are noted on cardiovascular, respiratory or abdominal examination.
Investigations reveal:
Full blood count normal.
ESR 28mm/hr (1-10)
Sodium 133 mmol/L (137-144)
Potassium 3.3 mmol/L (3.5-4.9)
Urea 8.8 mmol/L (2.5-7.5)
Creatinine 92 µmol/L (60-110)
Calcium 2.72 mmol/L (2.2-2.6)
Phosphate 0.8 mmol/L (0.8-1.4)
Free T4 17.8 pmol/L (10-22)
TSH 0.3 mU/L (0.5-4.0)
PTH 4 pmol/L (0.9-5.4)
Urinalysis Normal
Chest x ray Nil reported
What is the most likely cause of this person’s hypercalcemia?
A 45-year-old male presents with a six month history of fatigue, weight gain, and difficulty concentrating. He had surgery two years ago for a non-functional pituitary tumor and has been on replacement therapy with hydrocortisone, thyroxine, and testosterone. His lab results show low TSH and IGF-1 levels, but normal testosterone and free T4 levels. What treatment option would be most effective in improving this patient’s symptoms?
A 32-year-old male presents with fatigue and unintentional weight loss. Four years ago he was diagnosed with type 2 diabetes mellitus (T2DM) and has been managing it with metformin. However, over the last year, his blood sugar levels have been difficult to control and he has experienced several episodes of hypoglycemia. He has also noticed a decrease in his libido and erectile dysfunction.
Examination reveals a thin male (BMI 20) with a pulse of 80 beats per minute and a blood pressure of 120/80 mmHg. Cardiovascular, respiratory and abdominal examination were normal. Sensation was intact and fundal examination is normal.
Investigations reveal:
Serum sodium 135 mmol/L (137-144)
Serum potassium 4.0 mmol/L (3.5-4.9)
Serum urea 6.5 mmol/L (2.5-7.5)
Serum creatinine 90 µmol/L (60-110)
Serum glucose 8.5 mmol/L (3.0-6.0)
HbA1c 70 mmol/mol (20-42)
8.6% (3.8-6.4)
Serum calcium 2.4 mmol/L (2.2-2.6)
Serum phosphate 1.2 mmol/L (0.8-1.4)
Serum free T4 12.0 pmol/L (10-22)
Serum TSH 2.5 mU/L (0.4-5.0)
Serum testosterone 8.0 nmol/L (9.9-27.8)
Which of the following is the most appropriate investigation for this patient?
A 28-year-old female patient, who has a history of schizophrenia, presents to the Emergency Department with complaints of nausea and lethargy. Upon examination, the patient appears to be clinically euvolaemic with a Glasgow Coma Score (GCS) of 14. No focal neurological signs are observed. The patient’s serum sodium concentration is found to be 114 mmol/L, and there is no history of seizure activity. What is the most suitable course of action to correct the patient’s abnormal biochemistry?
A 25-year-old man presents with mild breast tenderness, weight loss and anxiety. He is known to have Klinefelter syndrome and had an undescended testis for which he underwent orchidopexy as a child. He has no other past medical history of note. On examination, his blood pressure (BP) is 120/70 mmHg, his body mass index (BMI) is 20, he has gynaecomastia and small testes, his left appears more swollen than the right, but he tells you this is the one he had the operation on.
Investigations:
– Haemoglobin (Hb): 130 g/l (135-175 g/l)
– White cell count (WCC): 17.2 x 10^9/l (4-11 x 10^9/l)
– Platelet (PLT): 250 x 10^9/l (150-400 x 10^9/l)
– Sodium (Na+): 142 mmol/l (135-145 mmol/l)
– Potassium (K+): 4.2 mmol/l (3.5-5.0 mmol/l)
– Creatinine: 70 µmol/l (50-120 µmol/l)
– Beta human chorionic gonadotropin (B-HCG) 9000 U/l < 5 U/l
– Thyroid-stimulating hormone (TSH) < 0.05 µU/l 0.17–3.2 µU/l
Which of the following is the next most appropriate investigation?
A 54-year-old man with a history of type 2 diabetes managed with Humalog mix 30 and metformin 1g BD presents for a check-up. His current HbA1c is 57 and he is experiencing troublesome hypoglycaemia episodes in the late afternoon and early mornings. What is the best course of action? On examination, his blood pressure is 132/82 mmHg, his pulse is regular at 72 beats per minute, and his BMI is 32 kg/m².
Investigations:
Na+ 139 mmol/l
K+ 4.9 mmol/l
Urea 5.1 mmol/l
Creatinine 94 µmol/l
HbA1c 57 mmol/mol
What is the most appropriate next step in his management?
The following results were obtained on dual energy x ray absorptiometry (DEXA) scan of the spine of a 65-year-old Postmenopausal Caucasian female who was concerned about her bone health, due to a personal history of fractures.
BMD T score Z score
L1-L4 0.85 -1.2 (82%) +0.5 (110%)
L2-L4 0.87 -1.1 (83%) +0.6 (112%)
L1 0.83 -1.3 (81%) +0.4 (109%)
What do these results indicate?
A 32-year-old patient is brought to the emergency department by ambulance with a decreased level of consciousness. She has a medical history of type 2 diabetes and emotionally unstable personality disorder. She takes metformin and gliclazide and smokes ten cigarettes daily. She is currently unemployed.
Upon examination, her heart rate is 111 beats per minute, blood pressure is 101/55 mmHg, respiratory rate is 21/minute, oxygen saturations are 96% on room air, and temperature is 37ºC. Her Glasgow coma scale is 9/15 (E1 V3 M5), and her neurological examination reveals normal tone and downgoing plantars. Her pupils are equal and reactive to light.
A bedside blood glucose level is measured at 1.8 mmol/L. Despite receiving 2 x 100ml boluses of 10% dextrose and subsequent dextrose infusion, the patient experiences recurrent hypoglycaemia.
What is the most appropriate pharmacological treatment to administer next?