A 28-year-old woman is referred to the Pregnancy Diabetes Clinic after two weeks of diet and exercise failed. Her first child was born at a normal size. She is currently 20 weeks pregnant and has no significant medical history. The following investigations were conducted:
Investigation Result
Fasting plasma glucose 6.9 mmol/l
Oral glucose tolerance test at 2 hours 11.4 mmol/l
What is the next best course of action in this scenario?
A 55-year-old woman with Graves’ disease presents for a check-up on her thyroid status. She is on propranolol and carbimazole. During the visit, she reports experiencing eye pain and double vision, especially when looking to the sides. Upon examination, there is significant proptosis. Her blood pressure is 122/82, pulse is regular at 60. Despite using artificial tears and eye patches, she has not found relief. What is the first-line treatment to improve her ophthalmopathy?
A 63-year-old man with a history of type 2 diabetes presents at the clinic for a check-up. He is currently being treated with BD mixed insulin and metformin to prevent weight gain associated with insulin use. The patient has a medical history of an inferior myocardial infarction and severe narrow-angle glaucoma. Recently, he has been experiencing severe burning pain in both of his lower legs.
During the examination, the patient’s blood pressure is 142/82 mmHg, pulse is 70 and regular. He has lost sensation below the knees in both legs. The following investigations were conducted:
– Haemoglobin: 127 g/L (135-177)
– White cell count: 6.9 ×109/L (4-11)
– Platelets: 189 ×109/L (150-400)
– Sodium: 138 mmol/L (135-146)
– Potassium: 4.9 mmol/L (3.5-5)
– Creatinine: 143 µmol/L (79-118)
– HbA1c: 63 mmol/mol (<48) or 7.9% (<6.5)
According to NICE guidance, what is the most appropriate way to manage his neuropathic pain?
A 70-year-old man with metastatic breast cancer arrives at the Emergency Department with complaints of worsening nausea and vomiting over the past 48 hours, along with increased thirst and urination. He also reports experiencing abdominal pain. The attending Emergency Medicine physician suspects hypercalcemia and orders an urgent calcium and albumin level. The patient’s corrected serum calcium level is 3.1 mmol/l.
Which of the following statements is true?
A 30-year-old female presents to the infertility clinic with an inability to conceive. She is overweight, with a body-mass index of 30 kg/m², and has noticed increased hair growth over her face and chest over the last 12 months. Her periods are irregular and she has also noticed a deepening of her voice. An ultrasound of the pelvis has revealed the presence of multiple cysts in both ovaries. She has been treated with cyproterone acetate for her hirsutism but was informed that she should not attempt conception whilst on the drug. She now wishes to conceive.
On examination, she has a cushingoid appearance, with abdominal striae and her blood pressure is 140/85 mmHg.
Laboratory investigations reveal:
9:00 am Cortisol 710 nmol/l (170 700 nmol/l)
LH 28 iU/l (1 20 iU/l)
Basal FSH 4.7 iU/l (1.0 8.8 iU/l)
DHEAS 509 µg/dl (31 228 µg/dl)
Prolactin 602 mU/l (<360 mU/l)
17 OH Progesterone 54 ng/dl (<80 ng/dl)
What is the most appropriate treatment option for infertility in this patient?
A 16-year-old male is admitted to the Emergency department with pneumonia. He has classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency and is currently taking prednisolone 7.5 mg daily and fludrocortisone 100 mcg/day. On examination, he has a temperature of 38.2°C, BP of 90/65 mmHg, pulse of 95 and regular, and signs of left lower lobe pneumonia. Investigations reveal abnormal levels of haemoglobin, white cell count, platelets, sodium, potassium, and creatinine. What would be your recommendation regarding the management of his steroid therapy?
A 75-year-old man visits the general medical clinic to discuss his recent blood test results. During a routine check-up, he was found to have low sodium levels. He has no symptoms of hyponatraemia and is clinically euvolaemic. However, a CT scan of his chest revealed radiological evidence of small cell lung cancer, which he has declined further investigation for. The medical team suspects he may have SIADH and wants to know what further investigations are necessary to confirm this.
Na+ 122 mmol/l
K+ 4.3 mmol/l
Urea 5.2 mmol/l
Creatinine 72 µmol/l
Serum osmolality 240 mmol/kg
A 65-year-old man with type 2 diabetes mellitus (insulin controlled) and end-stage renal failure (haemodialysis dependent for five years) was admitted to the coronary care unit six hours ago, with an acute inferior myocardial infarction.
Despite appropriate therapy, including thrombolysis, he continues to have ischaemic symptoms, and is in pulmonary oedema. His last haemodialysis session was 48 hours prior to admission. His blood pressure is 86/52 mmHg.
Investigations show:
– Serum sodium 139 mmol/L (137-144)
– Serum potassium 6.7 mmol/L (3.5-4.9)
– Serum urea 49 mmol/L (2.5-7.5)
– Serum creatinine 950 µmol/L (60-110)
– Haemoglobin 108 g/L (130-180)
– Troponin T >25 g/L (<0.04)
A transthoracic echocardiogram shows a left ventricular ejection fraction of 20%.
What is the most appropriate management strategy?
A 50-year-old female presents with a 3-year history of headache and visual blurring. When she first visited her GP 3 years ago, her blood pressure was found to be 240/165 mmHg. Despite being prescribed four different anti-hypertensives, including 50mg spironolactone, her blood pressure remains poorly controlled. Her recent blood tests show:
– Na+ 140 mmol/l
– K+ 2.8 mmol/l
– Urea 6.0 mmol/l
– Creatinine 80 µmol/l
– CRP 3 mg/l
Serum ambulatory renin activity 0.32 pmol/L @ 3-4 hours (normal range 0.8-3.5 pmol/ml/hr)
Serum ambulatory aldosterone 2100 pmol/L@ 3-4 hours (normal range 100-800)
A CT adrenal scan reveals a right adrenal mass measuring 2.5cm in diameter. The patient is eager to address the underlying issue. What is the most appropriate next step in management?
A 50-year-old male presents to his general practitioner with complaints of lethargy and weight loss over the past three months. He has a history of diabetes mellitus for the past six years and is currently taking gliclazide 160 mg daily and metformin 1 g twice daily. On examination, his BMI is 25.6 kg/m2, pulse is 88 beats per minute, and blood pressure is 164/102 mmHg. Fundal examination reveals dot haemorrhages in the temporal retina of both eyes with occasional hard exudates. Loss of position and vibration sensation are noted to the mid tibia bilaterally.
Further investigations reveal a haemoglobin level of 140 g/L, white cell count of 4.8 ×109/L, platelets of 195 ×109/L, serum sodium of 137 mmol/L, serum potassium of 4.6 mmol/L, serum urea of 16.7 mmol/L, serum creatinine of 220 µmol/L, HbA1c of 78 mmol/mol (9.3%), and urinalysis showing protein++ and blood+.
What is the most appropriate therapeutic strategy for this patient?