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SEND - Endocrinology and Diabetes (Specialty Certificate Examination) Questions 81–85 (page: 18)

A 55-year-old woman presented complaining of difficulty losing weight.
On examination, her blood pressure was 170/105 mmHg and urinalysis showed protein 1+.
An ultrasound scan of abdomen revealed a 4.5-cm solid lesion in the right adrenal gland. She was treated with ramipril and further endocrine evaluation was performed.

Investigations:
serum potassium3.6 mmol/L (3.5–4.9) serum creatinine135 µmol/L (60–110) plasma renin activity:
(after 30 min supine)3.9 pmol/mL/h (1.1–2.7)
(after 30 min upright)6.8 pmol/mL/h (3.0–4.3) plasma aldosterone:
(after 30 min supine)150 pmol/L (135–400)
(after 4 h upright)350 pmol/L (330–830)
serum cortisol (09.00 h)650 nmol/L (200–700)
serum cortisol (22.00 h)225 nmol/L (50–250) 24-h urinary free cortisol230 nmol (55–250) 24-h urinary dopamine3200 nmol (<3100)
24-h urinary adrenaline120 nmol (<144)
24-h urinary noradrenaline450 nmol (<570)

What is the most appropriate initial management of the adrenal lesion?

A 56-year-old man was referred to the diabetes clinic for conversion to insulin. He was taking metformin 1 g three times daily, gliclazide 160 mg twice daily and pioglitazone 45 mg daily. He drank no alcohol.
On examination, his body mass index was 41 kg/m2 (18–25). Abdominal examination showed a 2-cm, smooth, non-tender liver edge.
Which liver function test is the best marker of non-alcoholic fatty liver disease in type 2 diabetes mellitus?

A 48-year-old man was investigated for a 6-month history of tiredness. There was no other medical history and he was taking no medication.

Investigations:
-estimated glomerular filtration rate (MDRD)36 mL/min/1.73 m2 (>60) serum corrected calcium2.25 mmol/L (2.20–2.60)
-serum phosphate1.1 mmol/L (0.8–1.4)
-plasma parathyroid hormone8.1 pmol/L (0.9–5.4) serum 25-OH-cholecalciferol48 nmol/L (45–90)

What is the most important next step in management?

A 64-year-old man presented with palpitations, fatigue and malaise. Two months previously, he had sustained an acute myocardial infarction complicated by ventricular tachycardia and cardiac arrest, and had been discharged taking amiodarone 200 mg daily.
On examination, he appeared well, his pulse was 90 beats per minute and regular, and he had mild tremor of his hands but no other abnormal signs.

Investigations:
-serum thyroid-stimulating hormone6.2 mU/L (0.4–5.0) serum free T418.2 pmol/L (10.0–22.0)
-serum free T34.8 pmol/L (3.0–7.0)

What is the most appropriate next step in management?

A 56-year-old woman was referred for assessment of asymptomatic hypercalcaemia. Investigations:
serum corrected calcium2.73 mmol/L (2.20–2.60) plasma parathyroid hormone8.9 pmol/L (0.9–5.4) urinary calcium:creatinine clearance ratio0.002
An X-ray of abdomen was normal and imaging of her neck showed no evidence of a parathyroid adenoma. What is the pattern of inheritance of this condition?