A 50-year-old patient visits the endocrinology clinic due to a small thyroid nodule that was discovered incidentally. The patient reports a painless and non-tender 7mm nodule with no associated throat or systemic symptoms. The patient has a medical history of fibroids and post-partum depression but takes no regular medications. An ultrasound has been performed, and no malignant features were detected. What is the best course of action?
A 67-year-old man has been admitted with hypercalcaemia due to metastatic prostate cancer. CT scans have confirmed multiple bony, sclerotic metastases in the lumbar spine and pelvis. IV fluids have been administered since admission, and the patient has received IV pamidronate 60 mg three days ago and IV denosumab 120 mg yesterday. The adjusted calcium levels have been monitored and are as follows:
Day 1: 3.32 mmol/L
Day 2: 3.26 mmol/L
Day 3: 3.24 mmol/L
Today: 3.16 mmol/L (normal range: 2.1-2.6)
The patient’s renal function today is as follows:
Na+: 126 mmol/L (normal range: 135-145)
K+: 3.7 mmol/L (normal range: 3.5-5.0)
Bicarbonate: 23 mmol/L (normal range: 22-29)
Urea: 8.9 mmol/L (normal range: 2.0-7.0)
Creatinine: 132 µmol/L (normal range: 55-120)
What is the next appropriate step in managing this patient’s condition?
A 63-year-old man presents with breathing difficulty seven hours after undergoing thyroidectomy for hyperthyroidism. He reports feeling like his neck is tighter and the breathing difficulty has been worsening over the past hour. The patient has a medical history of COPD, angina, and ischemic heart disease. He takes aspirin, ramipril, Symbicort, bisoprolol, and atorvastatin, but stopped taking aspirin a week before surgery. On examination, his chest is clear, heart sounds are normal, and there is a small amount of strike-through bleeding from the neck wound. The patient’s heart rate is 90 bpm, blood pressure is 156/82 mmHg, and oxygen saturation is 89% on room air. His calves are soft and non-tender. What is the best course of action?
A 50-year-old male presents with difficulty sleeping, weight loss, and anxiety. He has been taking combined cyclical oestrogen/progesterone hormone replacement therapy for the past two years. On examination, he has a body mass index of 25 kg/m2, a pulse of 100 beats per minute, and a blood pressure of 118/76 mmHg. No goitre is palpable, and eye movements are normal. Weakness of the proximal musculature of the shoulder and hip girdles is noted. Abdominal examination reveals a palpable splenic tip.
Initial investigations reveal the following:
– Serum total thyroxine 260 nmol/L (60-140)
– Plasma TSH <0.1 mU/L (0.4-5.0)
– Serum alkaline phosphatase 190 U/L (45-105)
– Serum gamma glutamyl transferase 28 U/L (4-35)
The patient’s GP prescribes carbimazole 10 mg tds and propranolol 120 mg BD. At the six-week review, the patient appears clinically euthyroid. Repeat investigations show:
– Free thyroxine 190 nmol/L
– Plasma TSH 2.5 mU/L
– Serum alkaline phosphatase 170 U/L
– Serum gamma glutamyl transferase 35 U/L
The dose of carbimazole is decreased to 20 mg daily. After one year, the GP decides to refer the patient to endocrine outpatients. Two weeks before the appointment, the patient had a chest infection treated with erythromycin. His blood test results show:
– Serum thyroxine 85 nmol/L
– Plasma TSH 11.2 mU/L
– Serum alkaline phosphatase 100 U/L
What would be the most appropriate next investigation?
A 62-year-old man presents to the clinic for a review of his medical condition. He has a past medical history of ischemic heart disease and was diagnosed with type 2 diabetes mellitus about a year ago. His HbA1c at the time of diagnosis was 7.6% (60 mmol/mol), and he was started on metformin, which was gradually increased to a dose of 1g bd. His most recent blood test shows an HbA1c of 6.8% (51 mmol/mol). He has recently retired from his job in the IT industry, and his current BMI is 28 kg/m². He is taking the following medications:
– Atorvastatin 80 mg once daily
– Aspirin 75 mg once daily
– Bisoprolol 2.5 mg once daily
– Ramipril 5mg once daily
What would be the most appropriate next step for this patient?
A 49-year-old woman presents to the surgical ward with severe abdominal pain radiating from her loin to groin. A CT-KUB scan reveals the presence of a renal calculus on the right side. During the admission process, she confides in you that she has been feeling unwell for the past few weeks, experiencing symptoms such as altered mood, constipation, polyuria, and polydipsia.
Upon conducting blood tests, the following results were obtained:
– Estimated glomerular filtration rate >60 ml/min
– Adjusted calcium 3.1 mmol/l (2.1-2.6 mmol/l)
– Phosphate 0.6 mmol/l (0.8-1.4 mol/l)
– Parathyroid hormone 5.1 pmol/l (1.2-5.8 pmol/l)
What is the most probable cause of her symptoms?
A 40-year-old woman presents to the clinic with a three-month history of increasing fatigue, lethargy, and difficulty concentrating. She has also experienced nonspecific abdominal pain, resulting in weight loss due to a reduction in appetite. Despite the pain, she has not experienced any vomiting or diarrhea. She recently had to cut her holiday in Mexico short due to feeling unwell. On examination, she appears slim and tanned from her recent trip. Her vital signs are within normal limits, and her abdomen is soft and non-tender.
The following investigations were conducted:
– Hemoglobin: 128g/l (115-165)
– White blood cell count: 10.2 * 109/l (4.0-11.0)
– Sodium: 128 mmol/l (137-144)
– Potassium: 5.6 mmol/l (3.5-4.9)
– Urea: 10.8 mmol/l (2.5-7.0)
– Creatinine: 98µmol/l (60-110)
– Albumin: 38g/l (37-49)
– Alkaline phosphatase: 126U/l (45-105)
– ALT: 112U/l (5-35)
– Bilirubin: 12µmol/l (1-22)
– Alkaline phosphatase: 126U/l (45-105)
– Amylase: 826U/l (60-180)
– Calcium: 2.84mmol/l (2.20-2.60)
What is the most appropriate next step in making a diagnosis?
A 65-year-old man is admitted to the Emergency Department after being found confused by his wife. He has problems with mobility and hypertension, and takes a number of medications. According to his wife, he has been increasingly chesty with a cough productive of bloodstained sputum over the past three days.
On arrival in the Emergency Department, his blood pressure is 150/90 mmHg, pulse 76 bpm and regular and temperature 37.8 °C. There are signs of left-sided consolidation on auscultation. He is drowsy and confused and suffers a short (30 s) tonic–clonic seizure just after you complete your physical examination.
Investigations:
Investigations Results Normal Values
Haemoglobin (Hb) 135 g/l 130–170 g/l
White cell count (WCC) 12.5 × 109/l 4–11 × 109/l
Platelets (PLT) 180 × 109/l 150–400 × 109/l
Sodium (Na+) 130 mmol/l 135–145 mmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Creatinine 95 µmol/l 50–120 µmol/l
Glucose 8.5 mmol/l 3.5–5.5 mmol/l
C-reactive protein (CRP) 210 mg/l < 5 mg/l
Chest X-ray: Left lower lobe consolidation.
Which of the following is the most appropriate intervention in addition to antibiotic therapy?
A 43-year-old woman presented to the clinic with complaints of palpitation, tremor, and weight loss. She has no significant medical history and is not taking any regular medication.
During the physical examination, a palpable goitre, exophthalmos, and tremors of the outstretched hands were observed.
The thyroid function tests revealed:
– Free thyroxine (T4) 36 pmol/L (10-25)
– Free triiodothyronine (T3) 15 pmol/L (5-10)
– Thyroid-stimulating hormone 0.1mU/L (0.4-5.0)
What would be the initial treatment recommended to alleviate the symptoms?
You are urgently called to review a 44-year-old woman in the emergency department. She presented earlier in the day with fever, a productive cough and confusion. The emergency department doctors diagnosed her with community acquired pneumonia after seeing consolidation on her chest X-ray and sepsis secondary to this with associated delirium. According to her partner, she had been feeling unwell for two days with a cough and become increasingly unwell, confused and agitated. The partner also explained that she had recently been diagnosed with an overactive thyroid and been told to start urgently on anti-thyroid tablets, but had not done so when she had read the label of these tablets and found that they should not be taken during pregnancy and she is trying to become pregnant. She had been taking paracetamol only for fever.
Despite treating with IV co-amoxiclav and oral clarithromycin and fluid resuscitation with three liters of fluid as well as IV paracetamol the patient has not improved.
On examination, she is very agitated and aggressive and is difficult to examine. She feels very hot and clammy to touch, but peripheries are well perfused. Auscultation shows left sided crepitations. Her heart rate is 170 bpm, blood pressure 81/40 mmHg, temperature 39.2ºC, oxygen saturations 100% on 2L via nasal cannulae.
Blood tests from this admission are still pending. Outpatient blood tests show an undetectable low TSH two weeks ago, as well as a free T4 of 53 mmol/ml.
What is the most appropriate immediate treatment?