A 67-year-old woman presented to her general practitioner with a swelling in her neck. It had been present for 4C5 years and had not changed in size during that time. She was completely asymptomatic and remained well.

On examination, there was a nodular goitre and no lymphadenopathy.

Investigations:

serum thyroid-stimulating hormone1.1 mU/L (0.4C5.0)

A subsequent ultrasound scan demonstrated seven nodules bilaterally (ranging in size from 5 mm to 15 mm), which had no suspicious features.

What is the most appropriate next step in management according to British Thyroid Association 2014 Guidelines for the Management of Thyroid Cancer?

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A 17-year-old boy with type 1 diabetes mellitus was admitted with diabetic ketoacidosis precipitated by a recent viral illness.

Investigations on admission:

random plasma glucose15.0 mmol/L

arterial blood gases, breathing air:

pH7.07 (7.35C7.45)

H+85 nmol/L (35C45)

Investigations after initial treatment with fluids, insulin and potassium 7 h after admission:

random plasma glucose4.0 mmol/L

serum bicarbonate10 mmol/L (20C28)

At this stage, he was being given infusions of insulin (1 U/h) and glucose 5% (100 mL/h).

What is the most appropriate next step in management?

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A 17-year-old boy had panhypopituitarism, including diabetes insipidus, following treatment for a craniopharyngioma. He was taking appropriate replacement therapy. In the transition clinic, he was keen to continue growth hormone replacement therapy following a 12-month break after reaching final height.

Which is the most appropriate test to assess his growth hormone status?

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A 26-year-old woman with previously well-controlled primary hypothyroidism had been an in patient for treatment of an eating disorder for the previous 6 weeks. She had a history of anaemia resulting from multiple vitamin deficiency and gastric erosions. She had been taking levothyroxine 125 micrograms daily for the previous 5 years; since admission her medication had also included ferrous sulfate, calcium and vitamin D, and sucralfate. Her daily medicines were taken under supervision at 09.00 h. Although she was eating better and had gained 4 kg in weight, she was now complaining of tiredness and feeling "worse than ever".

On examination, she was thin, slightly pale and had no palpable goitre. Recent blood tests had confirmed that her anaemia had resolved.

Investigations:

serum corrected calcium2.28 mmo/L (2.20-2.60)

serum thryoid-stimulating hormone12.0 mU/L (0.4-5.0)

serum free T48.0 pmol/L (10.0-22.0)

serum T30.90 nmol/L (1.07-3.18)

What is the most appropriate next step in management?

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A 58-year-old man presented with tiredness and breathlessness. He had been treated for type 2 diabetes mellitus and hypertension for the past 10 years. He was free of complications. His current medication included ramipril 10 mg daily, rosuvastatin 10 mg daily, metformin 500 mg three times daily, dapagliflozin 10 mg once daily and exenatide 10 micrograms twice daily.

On examination, his body mass index was 36 kg/m2 (18C25).

Investigations:

haemoglobin93 g/L (130C180)

MCV110 fL (80C96)

white cell count3.6 ? 109/L (4.0C11.0)

platelet count140 ? 109/L (150C400)

reticulocyte count0.5% (0.5C2.4)

serum ferritin250 µg/L (15C300)

serum vitamin B1240 ng/L (160C760)

serum folate3.0 µg/L (2.0C11.0)

Which medication is most likely to be contributing to his anaemia?

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A 49-year-old woman presented with a slowly enlarging lump in her neck.

On examination, there was a 3.5-cm firm nodule in the left lobe of the thyroid gland, with no associated lymphadenopathy.

Investigations:

serum thyroid-stimulating hormone<0.05 mU/L (0.4C5.0)

serum free T426.0 pmol/L (10.0C22.0)

serum free T38.6 pmol/L (3.0C7.0)

An ultrasound scan showed an enlarged thyroid gland, with small nodules throughout. There was a larger hypoechoic 3.3-cm nodule with increased intranodular vascularity in the lower pole of the left lobe, with no associated lymphadenopathy.

What is the most appropriate management?

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A 16-year-old girl presented with primary amenorrhoea. In early childhood she had undergone an inguinal herniorrhaphy. She had no other medical history of note. There was a family history of infertility affecting a maternal aunt.

On examination, she had adult breast development but no pubic or axillary hair.

Examination was otherwise normal.

What test is most likely to aid diagnosis?

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A 17-year-old girl was referred to the outpatient clinic with irritability, weight loss and

difficulty sleeping. At the age of 4, she had presented with rapid growth, breast development and vaginal bleeding. The results of a gonadotropin-releasing hormone (GnRH) stimulation test performed at that time are given below.

serum oestradiolplasma FSHplasma LH

(200C400 pmol/L)(2.5C10.0 U/L)(2.5C10.0 U/L)

0 min365<0.7<0.5

30 minC<0.7<0.5

60 minC<0.7<0.5

She had been treated with GnRH analogue until the age of 11 and puberty had then progressed normally.

On examination, she was found to be tremulous, tachycardic and hyper-reflexic. Several large, irregular café-au-lait spots were found.

Investigations:

serum thyroid-stimulating hormone<0.05 mU/L (0.4C5.0)

serum free T436.0 pmol/L (10.0C22.0)

What is the most likely diagnosis?

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A 44-year-old man was referred for investigation of cortisol excess. He had poorly controlled hypertension, and a long history of type 2 diabetes mellitus with retinopathy and peripheral neuropathy. His medication comprised aspirin, ramipril, atenolol,

carbamazepine, metformin and simvastatin.

Initial investigations:

serum cortisol (09.00 h)350 nmol/L (200C700)

serum cortisol (22.00 h)48 nmol/L (50C250)

overnight dexamethasone suppression test (after 1 mg dexamethasone):

serum cortisol93 nmol/L (<50)

24-h urinary free cortisol (day 1)225 nmol (55C250)

24-h urinary free cortisol (day 2)200 nmol (55C250)

24-h urinary free cortisol (day 3)185 nmol (55C250)

What is the most appropriate next step in management?

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A 33-year-old woman was seen for diabetes review 2 months after her first pregnancy. Diabetes mellitus had been diagnosed at 18 weeks’ gestation. She had experienced no symptoms; routine urinalysis had shown glucose 4+, with no ketones, and her fasting blood glucose concentration was 6.2 mmol/L (3.0C6.0), rising to 13.5 mmol/L (<7.8) in a 75-g oral glucose tolerance test. She had been treated with insulin during the pregnancy, and stopped after delivery. Her mother and maternal aunt had been treated for type 2 diabetes mellitus, and a maternal uncle for type 1 diabetes. Her body mass index was 23.7 kg/m2 (18C25).

Without insulin she remained well, with no osmotic symptoms, no weight loss and no ketosis.

Investigations:

fasting plasma glucose8.4 mmol/L (3.0C6.0)

haemoglobin A1c68 mmol/mol (20C42)

oral glucose tolerance test (75 g):

fasting plasma glucose7.9 mmol/L (3.0C6.0)

2-h plasma glucose13.8 mmol/L (<7.8)

serum insulin72 pmol/L (<186)

serum C-peptide945 pmol/L (180C360)

A trial of therapy with gliclazide 40 mg once daily led to a significant improvement in her blood glucose.

What is the most likely cause of her diabetes?

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