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A 55-year-old woman presented with a 3-week history of nausea and vomiting. Her only medical complaints were frequent dyspepsia, for which she was taking indigestion tablets, and asthma for which she was taking a salbutamol inhaler as required.
On examination, there was no evidence of lymphadenopathy, her chest was clear on auscultation and abdominal examination was normal.
Investigations (before and after taking omeprazole for 3 weeks):
beforeafternormal erythrocyte sedimentation rate (mm/1st h)44<30 serum creatinine (umol/L)17011060-110 serum corrected calcium (mmol/L)2.852.402.20-2.60
serum phosphate (mmol/L)1.90.8-1.4
serum angiotensin-converting enzyme (U/L)8525-82
plasma parathyroid hormone (pmol/L)0.44.40.9-5.4
What is the most likely cause of the hypercalcaemia?

• A. parathyroid hormone-related peptide-secreting malignancy
• B. primary hyperparathyroidism
• C. milk-alkali syndrome
• D. multiple myeloma
• E. sarcoidosis

A 28-year-old man was seen in the lipid clinic following a referral from the general surgical team. He had had two episodes of acute pancreatitis over the preceding 6 months, which settled spontaneously. He had a past medical history of HIV disease and was taking highly active antiretroviral (HAART) therapy. He drank 12 units of alcohol per week.
On examination, he had no stigmata of hyperlipidaemia.
Investigations:
fasting plasma glucose6.2 mmol/L (3.0-6.0)
haemoglobin A1c44 mmol/mol (20-42)
serum cholesterol7.5 mmol/L (<5.2)
fasting serum triglycerides23.70 mmol/L (0.45-1.69)
serum thyroid-stimulating hormone0.7 mU/L (0.4-5.0)
serum free T414.3 pmol/L (10.0-22.0)
What class of antiretroviral drug is the most likely cause of his metabolic disturbance?

• A. non-nucleoside reverse transcriptase inhibitors (e.g. nevirapine)
• B. protease inhibitors (e.g. ritonavir)
• C. entry inhibitors (e.g. enfuvirtide)
• D. integrase inhibitors (e.g. raltegravir)
• E. nucleoside reverse transcriptase inhibitors (e.g. zidovudine)

A 15-year-old boy was referred by the school nurse because she was concerned about his weight. There was no past history of note. He was not taking any medication. His height was 1.61 m and he weighed 70.5 kg.
Investigations: growth chartsee image

What is the most likely diagnosis?

• A. Cushing's disease
• B. simple obesity
• C. leptin deficiency
• D. Prader-Willi syndrome
• E. growth hormone deficiency

A 27-year-old woman presented with a 6-month history of amenorrhoea and low mood. She complained of headaches but no visual disturbance. Her past medical history included anorexia nervosa but her current weight was stable.
On examination, her body mass index was 20.2 kg/m2 (18-25). Routine physical examination was normal and there was no galactorrhoea. Visual fields were full to confrontation.
Investigations:
serum cortisol (09.00 h)320 nmol/L (200-700)
short tetracosactide (Synacthen@) test (250 micrograms): serum cortisol (30 min after tetracosactide)630 nmol/L (>550) serum oestradiol200 pmol/L (200-400) plasma follicle-stimulating hormone2 U/L (2.5-10.0) plasma luteinising hormone4 U/L (2.5-10.0)
serum prolactin1001 mU/L (<360) serum free T418.0 pmol/L (10.0-22.0)
serum ?-human chorionic gonadotropin<5 U/L (<5)
What is the most appropriate next step in management?

• A. pregnancy test
• B. ultrasound scan of ovaries
• C. encourage weight gain and reassess after 2 months
• D. MR scan of pituitary
• E. start cabergoline 0.5 mg/week

A 46-year-old South Asian man presented with a 2-month history of dry mouth and polyuria. He had hypertension treated with bendroflumethiazide. There was no family history of diabetes mellitus, but his father had died suddenly during lower limb angioplasty at the age of 51.
On examination, the patient's pulse was 76 beats per minute and regular, and his blood pressure was 164/86 mmHg. The rest of the physical examination was normal. Urinalysis was normal.
Investigations:
serum sodium143 mmol/L (137-144)
serum potassium3.0 mmol/L (3.5-4.9)
serum creatinine123 umol/L (60-110)
fasting plasma glucose6.9 mmol/L (3.0-6.0)
What is the most appropriate next step in management?

• A. start oral hypoglycaemic treatment
• B. haemoglobin A1c measurement
• C. oral glucose tolerance test
• D. repeat fasting plasma glucose
• E. change bendroflumethiazide to ramipril