AKT – Endocrine and metabolic health

Mark Jennings, aged 54, presents with a 6-month history of fatigue, weight gain, and cold intolerance. He also describes constipation and mild depressive symptoms.

He takes atenolol for hypertension. On examination, he has bradycardia, dry skin, periorbital puffiness, and delayed ankle reflexes.

His TSH is elevated at 12.8 mIU/L and free T4 is low at 7.3 pmol/L.

What is the most appropriate next step in management?

Rachel Li, aged 32, presents for review of her polycystic ovary syndrome (PCOS). She is overweight with a BMI of 31 and trying to conceive.

She has irregular periods and elevated serum total testosterone. Pelvic ultrasound confirms multiple ovarian follicles.

What is the most appropriate first-line pharmacological therapy to assist ovulation?

Angela Barlow, aged 66, presents with progressive fatigue and low sodium (Na 126 mmol/L). She takes hydrochlorothiazide and sertraline.

On examination she is normotensive, has no oedema, and is euvolaemic. Urine sodium is elevated and serum osmolality is low.

What is the most likely diagnosis?

David Nguyen, aged 47, has just returned from a fly-in-fly-out job and presents with nausea, abdominal pain, and dizziness. BP is 90/60 mmHg supine, dropping to 72/50 on standing.

His serum sodium is 124 mmol/L, potassium 5.8 mmol/L, and glucose 3.2 mmol/L.

He has increased skin pigmentation over his knuckles and palmar creases.

What is the most appropriate next investigation?

Joanna Marshall, aged 61, presents with recent onset of blurred vision and thirst. Her random BGL is 16.2 mmol/L. She has no ketones and is not acutely unwell.

She has hypertension and hyperlipidaemia, and takes ramipril and atorvastatin.

Her HbA1c returns at 8.3% (67 mmol/mol).

What is the most appropriate initial management strategy?

Aliyah Khan, aged 29, presents with persistent amenorrhoea and galactorrhoea. She is not currently breastfeeding. She is otherwise well with no headache or visual disturbance.

Her serum prolactin is 1320 mIU/L (normal <500). Beta-hCG is negative. TSH and renal function are normal.

What is the most appropriate next investigation?

Steven Aldridge, aged 63, presents for routine review. He has type 2 diabetes managed with metformin and empagliflozin. He recently experienced an episode of dizziness and fatigue after gardening in hot weather.

His glucose was 3.2 mmol/L during the episode. He denies skipping meals. No insulin or sulfonylureas are used.

What is the most likely cause of his hypoglycaemia?

Matthew Clark, aged 34, presents with a 2-year history of primary infertility. Semen analysis is normal. His testosterone is low and FSH and LH are elevated. He has small firm testes bilaterally.

What is the most likely diagnosis?

Maria O’Shea, aged 75, is brought in by her daughter due to confusion and frequent falls. She has been taking vitamin D supplements and recently started calcium carbonate for osteoporosis.

Bloods reveal: calcium 3.02 mmol/L (↑), PTH suppressed, eGFR 68 mL/min. She is otherwise haemodynamically stable.

What is the most likely cause of her hypercalcaemia?

Yen Tran, aged 42, is found to have a fasting glucose of 5.9 mmol/L and HbA1c of 6.0% (42 mmol/mol) on routine screening. She has a family history of type 2 diabetes and a BMI of 27.

She is asymptomatic and not on any medications.

What is the most appropriate interpretation and advice?

Luke Harrison, aged 36, presents with episodes of tremor, sweating, palpitations and confusion, mostly occurring in the morning before breakfast. He is otherwise well and takes no regular medications.

On examination he is slim and well-appearing. Capillary BGL during a symptomatic episode is 2.1 mmol/L and improves after eating.

What is the most appropriate initial investigation?

Gillian Rees, aged 49, presents with weight gain, easy bruising and irregular menses. She is hypertensive and has purple striae across her abdomen. Her dexamethasone suppression test shows no suppression of cortisol levels.

What is the most appropriate next investigation?

Simon Braddock, aged 55, presents with erectile dysfunction and reduced libido. He is otherwise well with no major past medical history. Examination reveals small testes and decreased pubic hair.

Initial bloods show low testosterone and low LH and FSH.

What is the most likely diagnosis?

Louisa Micallef, aged 60, presents with recent diagnosis of osteoporosis. She has no history of fractures. Her T-score at the femoral neck is -2.8. She is a non-smoker and consumes 2-3 standard drinks per day.

She is intolerant to oral bisphosphonates due to severe reflux symptoms.

What is the most appropriate next step in management?

Noelene Ryan, aged 72, presents with new fatigue and weakness. She has recently developed polyuria and polydipsia. Blood tests reveal calcium 3.18 mmol/L, PTH suppressed, phosphate low, and creatinine mildly elevated.

She has a 20-pack-year smoking history and weight loss over the past 3 months.

What is the most likely underlying cause of her hypercalcaemia?

Hassan Alvi, aged 40, presents with recent diagnosis of Graves’ disease confirmed by positive TSH receptor antibodies and elevated T4. He has mild tremor and weight loss, and is otherwise well. He asks about treatment options.

What is the most appropriate initial treatment?

Emily Browne, aged 23, presents with concerns of excessive hair growth on her face and chest. She has irregular menstrual cycles and struggles with acne. BMI is 33. Examination reveals hirsutism and mild acanthosis nigricans.

What is the most appropriate initial investigation?

George Apostolou, aged 68, is being treated for metastatic prostate cancer. He presents with progressive fatigue and nausea. On examination, he is hypotensive and tanned. Labs reveal hyponatraemia and hyperkalaemia.

What is the most appropriate initial management?

Charlotte Worth, aged 35, is 8 weeks pregnant and has a history of hypothyroidism managed with levothyroxine. Her TSH is currently 5.8 mIU/L (↑), with a normal free T4. She is clinically euthyroid.

What is the most appropriate next step?

Darryl Ng, aged 61, presents with new-onset diabetes. He has BMI of 23 and reports unintentional weight loss and diarrhoea. Examination reveals erythematous rash on his legs and normotensive blood pressure.

Which underlying condition should be considered?

Isabelle Dupont, aged 48, is referred with concerns about recurrent kidney stones. She has no past medical history and no family history of stones. Bloods show calcium 2.84 mmol/L, phosphate low, PTH elevated. Vitamin D is normal.

What is the most likely diagnosis?

Nathan Ellis, aged 45, presents for cardiovascular risk assessment. His fasting lipids reveal triglycerides of 6.4 mmol/L. He has a BMI of 32, drinks 4 standard drinks daily and has type 2 diabetes.

What is the most appropriate initial management step?

Michelle Rowe, aged 39, presents with fatigue, menstrual irregularity and hair thinning. Examination shows dry skin and bradycardia. TSH is 8.6 mIU/L and free T4 is 13.2 pmol/L (normal).

What is the most appropriate next step in management?

Leo D’Silva, aged 65, presents with persistent low back pain. He has a history of longstanding poorly controlled type 2 diabetes. X-ray reveals vertebral fractures. DEXA shows a T-score of -2.6.

What is the most appropriate treatment?

Katie Freeman, aged 18, is being evaluated for primary amenorrhoea. She has normal breast development but scanty pubic hair. Pelvic ultrasound shows absence of uterus. Karyotype reveals 46,XY.

What is the most likely diagnosis?

Brian Moore, aged 52, presents for review of his recently diagnosed type 2 diabetes. His HbA1c is 7.8%. He is overweight with a BMI of 31, and his renal function is normal. He has no cardiovascular disease or microvascular complications.

He was started on metformin 2 months ago with good adherence.

What is the most appropriate next step in management?

Claire Bentley, aged 36, presents with increasing thirst and urination. Fasting glucose is 5.1 mmol/L, serum sodium is 148 mmol/L, and serum osmolality is elevated. Urine osmolality is low despite hypernatraemia.

She has no past medical history and takes no medications.

What is the most likely diagnosis?

Susan Karimi, aged 50, presents with ongoing fatigue, muscle weakness and constipation. She takes no medications. Her BP is 155/95 mmHg. Bloods show: sodium 142, potassium 3.1, bicarbonate 32.

What is the most appropriate next investigation?

Emily Zhang, aged 28, presents with fatigue and irritability. She has lost 5 kg unintentionally over the past month and feels constantly warm. Examination reveals fine tremor and a resting pulse of 108 bpm. Her TSH is <0.01 mIU/L and free T4 is mildly elevated.

Thyroid scintigraphy shows low uptake.

What is the most likely diagnosis?

Garry Munro, aged 67, presents with lethargy and low libido. Investigations show total testosterone of 5.2 nmol/L (low), LH and FSH also low. MRI brain reveals a 1.5 cm pituitary mass compressing the optic chiasm.

What is the most appropriate next step?

Alice Murray, aged 30, presents with fatigue and cold intolerance. She is 8 weeks postpartum. Examination reveals a flat affect, dry skin, and mild hypotension. Bloods reveal low free T4 and low TSH.

What is the most likely diagnosis?

Damien Webb, aged 44, presents with recent onset of bilateral gynaecomastia and decreased libido. He is not taking any medications. Examination reveals testicular mass on the right.

Which tumour marker is most useful in this context?

Jackie Thomas, aged 73, is concerned about new onset fatigue, confusion, and constipation. Medications include lithium for bipolar disorder. Bloods show calcium 2.92 mmol/L, PTH elevated.

What is the most likely explanation for her findings?

Fatima Ali, aged 24, presents with oligomenorrhoea and elevated serum testosterone. Her pelvic ultrasound is normal. BMI is 29. She is concerned about fertility.

What additional criterion is required to confirm PCOS?

Patrick Jansen, aged 58, is undergoing assessment for adrenal insufficiency. His short Synacthen test shows baseline cortisol of 140 nmol/L and 30-minute cortisol of 180 nmol/L.

What is the most appropriate interpretation?

Yvonne Tran, aged 64, presents with new onset hypertension and is found to have an adrenal incidentaloma on abdominal CT. She has no clinical features of Cushing’s syndrome. Blood pressure is 155/95 mmHg on one agent.

What is the most appropriate next step in evaluating the adrenal lesion?

Peter Wallace, aged 59, is on chronic prednisone therapy for polymyalgia rheumatica. He is undergoing a colonoscopy and is concerned about the stress of the procedure.

He currently takes prednisone 7.5 mg daily. He is otherwise stable and well.

What is the most appropriate management in relation to his steroids?

Laura Nguyen, aged 25, presents with anxiety, palpitations, and weight loss. Her TSH is suppressed and free T4 is elevated. She also has a tender, enlarged thyroid.

Which investigation would best distinguish between Graves’ disease and subacute thyroiditis?

Michael Callahan, aged 33, presents with delayed puberty. He has small testes and sparse body hair. Karyotype returns as 47,XXY.

What is the most likely diagnosis?

Debra Collins, aged 71, presents with recent fatigue and low mood. She has a long-standing history of type 2 diabetes, hypertension and osteoarthritis. Bloods reveal sodium 127 mmol/L, serum osmolality 260, and urine sodium 44 mmol/L.

She is clinically euvolaemic. Which medication is the most likely cause?

Andrew Lake, aged 49, presents for routine check-up. His BMI is 26 and blood pressure is 130/80 mmHg. Blood tests show fasting glucose 5.9 mmol/L and HbA1c 6.1% (43 mmol/mol).

What is the most appropriate next step in management?

Jasmine Khoo, aged 27, presents with concerns about irregular periods and infertility. Bloods show elevated testosterone and normal LH and FSH. Pelvic ultrasound confirms multiple peripheral follicles.

She has a BMI of 30 and no other comorbidities.

What is the most appropriate first-line intervention?

Chris Nolan, aged 56, presents with muscle weakness and weight gain. He has a round face, central adiposity, and purple striae on his abdomen. He takes no corticosteroids.

Which test is most appropriate to screen for Cushing’s syndrome?

Sally Buckley, aged 34, is pregnant at 10 weeks and has just been diagnosed with gestational diabetes following an abnormal OGTT. She is otherwise well and takes no medications.

What is the most appropriate first-line management?

Tom Waller, aged 62, presents with progressive fatigue and darkening of his skin. Blood pressure is 90/60 mmHg and HR 88 bpm. Labs show Na 126 mmol/L, K 5.6 mmol/L, glucose 3.3 mmol/L.

What is the most appropriate immediate management?

Heather Maclean, aged 47, presents with new onset hirsutism, deepening of the voice, and irregular periods. Serum testosterone is markedly elevated and DHEAS is also high.

What is the most appropriate next investigation?

Samira Dabbous, aged 38, presents for management of known prolactinoma. She is planning pregnancy. MRI shows a 4 mm microadenoma. Her prolactin is mildly elevated and menses are regular on cabergoline.

What is the most appropriate next step?

Damien Cook, aged 72, presents with a fall and is found to have a Colles fracture. He has a past history of smoking and hypertension. A DEXA scan shows a T-score of –2.4.

What is the most appropriate treatment strategy?

Kaitlyn De Sousa, aged 22, presents with persistent tachycardia and tremor. She has recently been treated with amiodarone for SVT. TFTs show low TSH and high free T4. Thyroid scan reveals low uptake.

What is the most likely diagnosis?

Kaitlyn De Sousa, aged 22, presents with persistent tachycardia and tremor. She has recently been treated with amiodarone for SVT. TFTs show low TSH and high free T4. Thyroid scan reveals low uptake.

What is the most likely diagnosis?

Vincent Huynh, aged 66, has longstanding type 2 diabetes and stage 3 CKD. His HbA1c is 7.9% despite maximum metformin and lifestyle efforts. eGFR is 38 mL/min.

What is the most appropriate next pharmacological agent?