Endocrine

A 32-year-old man presents to the emergency department with epigastric pain and vomiting. Point-of-care glucose is 25 mmol/L and urinalysis is strongly positive for ketones. Venous blood gas shows pH 7.08, pCO2 32 mmHg, pO2 45 mmHg. Electrolytes reveal sodium 136 mmol/L, potassium 5.8 mmol/L, chloride 100 mmol/L, and bicarbonate 6 mmol/L. After commencing appropriate intravenous fluid resuscitation, which of the following is the most appropriate next step in management?

A 40-year-old woman is reviewed after a thyroid ultrasound, performed following an incidental palpable nodule noted on a routine health check. She is asymptomatic, with no dysphagia, hoarseness, weight change or family history of thyroid malignancy. Vital signs are normal. On examination there is a small, mobile, non-tender nodule in the right thyroid lobe without cervical lymphadenopathy or tracheal deviation. Ultrasound shows a solitary 0.8 cm hypoechoic nodule with irregular margins and microcalcifications confined to the right lobe, with no suspicious cervical nodes. Fine-needle aspiration cytology confirms papillary thyroid carcinoma (Bethesda VI), and staging confirms T1aN0M0 disease. What is the most appropriate management?

A 60-year-old woman attends her GP for a routine osteoporosis review. She was diagnosed with post-menopausal osteoporosis 5 years ago and has been adherent to oral alendronate 70 mg weekly since then, taken correctly with adequate calcium and vitamin D intake. She has had no fragility fractures, no falls, and reports no new back pain, hip pain or dental problems. She does not smoke, drinks alcohol occasionally, and has no history of chronic kidney disease or long-term corticosteroid use. Examination is unremarkable with no height loss or spinal tenderness. A repeat DXA scan shows a lumbar spine T-score of -2.0 (previously -2.8) and femoral neck T-score of -2.1. Her FRAX-estimated 10-year major osteoporotic fracture risk is low. What is the most appropriate next step in her management?

A 70-year-old man presents to the emergency department with a two-day history of lethargy, mild nausea and reduced appetite. He was commenced on sertraline three weeks earlier by his general practitioner for low mood following his wife's death. He has no vomiting, diarrhoea or diuretic use, and denies polyuria or polydipsia. On examination he is alert and orientated, normotensive with no postural drop, and clinically euvolaemic with no oedema, ascites or signs of dehydration. Observations are otherwise unremarkable. Serum sodium is 128 mmol/L, serum osmolality is low, and urine osmolality and urine sodium are both elevated. Renal, thyroid and adrenal function are normal, and there is no clinical or radiological evidence of malignancy. He has no seizures, confusion or reduced conscious state.

A 60-year-old woman with postmenopausal osteoporosis (lumbar spine T-score -2.8) has been treated with denosumab 60 mg subcutaneously every 6 months for the past 5 years, with good tolerance and no fractures. Her most recent DEXA shows a substantial improvement in bone mineral density. She is now concerned about long-term risks of atypical femoral fracture and osteonecrosis of the jaw and wishes to cease therapy; her next scheduled injection is due in three weeks. She is asymptomatic with no back pain, recent falls or new deformity. Which of the following is the most appropriate management plan for discontinuing her denosumab?

A 40-year-old woman with a background of type 2 diabetes mellitus and stage 3b chronic kidney disease (baseline eGFR 30 mL/min/1.73m²) presents to the emergency department with three weeks of worsening fatigue and reduced exercise tolerance. She denies dyspnoea at rest, chest pain, melaena, haematochezia, haematuria or menorrhagia; her periods are regular and light. She has no history of NSAID use and takes metformin, a DPP-4 inhibitor and perindopril. On examination she is afebrile, BP 138/82 mmHg, HR 92 bpm regular, RR 16/min, SpO2 98% on room air. She appears mildly pale with pale conjunctivae but no jaundice, lymphadenopathy, hepatosplenomegaly or peripheral oedema, and abdominal and rectal examination (including faecal occult testing) are unremarkable. Bloods show haemoglobin 95 g/L (normocytic), normal white cell and platelet counts, urea 14 mmol/L, creatinine 180 µmol/L (eGFR 30 mL/min/1.73m²), and HbA1c 8.1%. Iron studies, reticulocyte count and vitamin B12/folate have not yet been sent. What is the most appropriate next step in managing her anaemia?