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SEND - Endocrinology and Diabetes (Specialty Certificate Examination) Questions 61–65 (page: 14)

A 16-year-old boy was referred with concern about delayed puberty. His stature had been short as a child. He reported an increase in height at the age of 13, and had begun to develop pubic hair at the age of 14. He reported no further growth or development in the past year. His father recalled going through puberty at the age of 13.
On examination, his height was 1.60 m (between 0.4th and 2nd centile), weight was 56.4 kg (between 9th and 25th centile), genital development was Tanner stage 2 and testicular volume was 8 mL bilaterally. Pubic hair was Tanner stage 2, with no evidence of androgenic axillary hair. Bone age at the left wrist was 13.5 years.

Investigations:
serum testosterone2.9 nmol/L (9.0–35.0)

Which feature in his clinical presentation most strongly suggests a diagnosis other than constitutional delay?

A 61-year-old woman was referred to the blood pressure clinic because of refractory hypertension. One year previously, her blood pressure, urea and electrolytes had been normal. Her current therapy included verapamil modified-release 240 mg daily and doxazosin 16 mg daily.
On examination, she was 1.63 m tall and weighed 90 kg with an elevated waist to hip ratio. Her blood pressure was 182/94 mmHg supine.

Investigations:
-serum sodium137 mmol/L (137–144) serum potassium2.8 mmol/L (3.5–4.9) serum creatinine79 µmol/L (60–110)
-plasma renin activity (after 30 min supine)<1.1 pmol/mL/h (1.1–2.7) plasma aldosterone (after 30 min supine)<135 pmol/L (135–400)

What is the most appropriate investigation?

A 67-year-old woman presented to her general practitioner with a swelling in her neck. It had been present for 4–5 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 (0.4–5.0)
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?

An 18-year-old woman was found to have a blood pressure of 164/102 mmHg at a pre-employment medical examination. She gave no family history of hypertension. On enquiry, she said that she had not yet started to menstruate.
On initial clinical examination, she appeared well. She was 1.72 m tall (>90th centile) and had a body mass index of 22 kg/m2 (18–25). There was no evidence of axillary hair, and pubic hair was scanty (Tanner stage 1). Breast development was immature (Tanner stage1).

Investigations:
-serum sodium142 mmol/L (137–144) serum potassium2.7 mmol/L (3.5–4.9) serum urea4.6 mmol/L (2.5–7.0) serum creatinine102 µmol/L (60–110)
-estimated glomerular filtration rate (MDRD)>60 mL/min/1.73 m2 (>60) plasma renin activity (after 30 min supine)1.0 pmol/mL/h (1.1–2.7) plasma aldosterone (after 30 min supine)125 pmol/L (135–400)
-serum cortisol (09.00 h)190 nmol/L (200–700)

What is the most likely underlying diagnosis?

A 63-year-old woman with diet-controlled type 2 diabetes mellitus was admitted with biventricular cardiac failure. She had a history of myocardial infarction 3 years previously. She was taking aspirin 75 mg daily, simvastatin 20 mg daily, furosemide 40 mg daily and ramipril 10 mg daily. She responded well to increased diuretic therapy.

Urinalysis showed glucose 1+. Investigations:
-haemoglobin112 g/L (115–165) serum sodium135 mmol/L (137–144) serum potassium4.7 mmol/L (3.5–4.9) serum creatinine162 µmol/L (60–110)
-estimated glomerular filtration rate28 mL/min/1.73 m2 (>60) serum troponin T<0.01 µg/L (<0.01)
-haemoglobin A1c66 mmol/mol (20–42)

What is the most appropriate treatment for her diabetes after discharge?