Endocrinology 🧪

A 45 year old Asian woman attends the GP surgery for her blood results. She had her blood test taken a week ago when she attended the surgery for symptoms of tiredness. She has a strong family history of diabetes mellitus type 2. She is a non-smoker and has a BMI of 19 kg/m2. Her blood results show.

Fasting glucose 8.0 mmol/L

Haemoglobin 140 g/L (115-160 g/L)

Renal function normal

Her blood pressure taken in the clinic was 145/80 mmHg. She has no history of stroke or myocardial infarction. What is the SINGLE most appropriate action?

A 19 year old man presents with weight loss, increased thirst and increased frequency of going to the washroom. His father, grandfather and his 2 sisters have been diagnosed with diabetes mellitus. His blood test shows a HbA1c of 62 mmol/mol ( < 48) and a fasting blood glucose of 9 mmol/L (<7). What is the SINGLE most likely type of diabetes this man suffers from?

A 36 year old woman complains of tiredness and lethargy over the past 6 months. She has dry skin and complains of cold intolerance. Her medical history includes type 1 diabetes. On examination, her thyroid gland is smooth and slightly enlarged. Her recent blood results show the following:

Thyroid stimulating hormone (TSH) 25.9 mU/L (0.5-5.7)

Free thyroxine (T4) pmol/L 1 (9-18)

What is the SINGLE most likely diagnosis?

A 68 year old woman was diagnosed with Type 2 Diabetes Mellitus. Diet and lifestyle modifications have failed to control her blood sugar levels over the last three months. She has no known allergies and takes ramipril 5mg once a day and bisoprolol Smg once a day for her management of heart failure. She has a body mass index of 35 kg/m2. Her blood results are as follows:

Serum urea 13.2 mmol/L

Creatinine 390 mmol/L

eGFR 14 ml/min

HbA1c 70 mmol/mol (Target <48 mmol/mol)

What is the SINGLE most appropriate pharmacological management?

A 40 year old man presents to the GP surgery with increased intake of water and increased frequency in urination over the past 4 weeks. He drinks up to 8 litres a day, He drinks around 8 cups of coffee. He has also lost 7 kg in the past 4 weeks. He has a BMI of 24 kg/m2. He also complains of a rash on his penis which sore. On examination, there are raised red dots of the glans penis. The foreskin is tight to retract. What is the SINGLE most appropriate diagnostic test to perform?

A 55 year old woman has recently been diagnosed with type 2 diabetes mellitus. Her body mass index is 23 kg/m2. Her last two random blood sugars that were taken were 8 and 7 mmol/L. Her clinic blood pressure reading is 165/94 mmHg with an ambulatory blood pressure reading average of 161/94. Her total cholesterol is 4.7mmol/l. She has no symptoms but has microalbuminuria seen on two separate occasions. She is a non- smoker. What is the SINGLE most appropriate drug management?

A 10 year old boy has developed hyperpigmentation that has become more obvious aver the past few months. He has penile enlargement. He had signs of puberty before age 9. He has no relevant past medical history. His blood test is seen below:

Serum sodium 119 mmol/L (125-135)

Serum potassium 5.9 mmol/L (3.5-5.5)

Which is the most appropriate biochemical test to perform to confirm a diagnosis?

A 29 year old known diabetic man comes to A&E after falling down the stairs. While waiting in the waiting room, he becomes unconscious and collapses. What is the SINGLE most appropriate initial investigation?

A 35 year old woman presented to the GP surgery 6 months ago complaining of excessive thirst, frequent micturition and unintentional weight loss for 4 months. A HbA1c performed, established diagnosis of diabetes mellitus. She was advised to implement lifestyle changes and was subsequently started on metformin. However, a recent HbA1c indicates that her glycaemic control is poor. On further discussion, she reveals that her mother had vitiligo, and her sister was diagnosed with Grave’s disease two years ago. Which of the following is the SINGLE most appropriate investigation to differentiate type 1 diabetes mellitus from type 2 diabetes mellitus?

An 8 month old infant presents with failure to thrive and constipation. His parents moved to the UK from Malawi when he was 3 months old. On examination, a protruding tongue and widely set eyes are observed. His father and older sister have had a history of prolonged neonatal jaundice. What is the SINGLE most likely diagnosis?

A 44 year old woman complains of fatigue and easy skin bruising. She has been put on 10 kg over the past 12 weeks and now weighs 95 kg. She notices that she is constantly hungry. She feels weak and finds it increasingly difficult to climb stairs or lift boxes at work. On examination, she has purple striae on her abdomen. Her blood pressure is 161/91 mmHg. Recent blood results are shown below:

Haemoglobin 125 g/L (115-160)

Sodium 142 mmol/L (135-145)

Potassium 3.3 mmol/L (3.5-5.0)

What is the SINGLE most appropriate initial investigation?

A 40 year old man was seen in the GP clinic with his partner for a history of collapse the day before. He was with his partner at the time of the incident. His partner claims that he was jogging when he suddenly collapsed. He regained consciousness a minute later. He remembers having a terrible headache, feeling warm and sweaty and his heart racing shortly before the incident. He notes that he had similar headaches in the past which were accompanied by sweating and flushing. He does not have a significant past medical history, although his blood pressure recorded during one of his episodes of headache was recorded as 185/110 mmHg but was found to be normal on a subsequent visit to his GP. On examination, his heart rate is 90 beats/minute, and blood pressure is 160/90mmHg. A subsequent ambulatory blood pressure monitor had an average reading of 170/100 mmHg. Which of the following is the SINGLE most appropriate investigation?

A 24 year old schizophrenic has been taking antipsychotic medication for the past year. He complains of feeling dizzy and has been experiencing erectile dysfunction. Which is the MOST likely antipsychotic medication to have caused his presenting symptoms?

A 24 year old woman stopped taking combined oral contraceptive pills 11 months ago as she and her partner would like to have a child. They have been having regular intercourse but she fails to become pregnant. She has not had her menstrual period since stopping the contraceptive pill. Her urine HCG is negative.

Her blood results show.

Follicle-stimulating hormone (FSH) 11 IU/L L

uteinizing Hormone (LH) 15 IU/L

Prolactin 2500 ng/mL

Oestradiol 53 pmol/L

What is the SINGLE most likely cause?

A 23 year old woman presents to the female health clinic with secondary amenorrhoea for a duration of 10 months. Her BMI is 30. She has dark pigmentation on her neck and severe acne on her face. She complains of feeling weak and lethargic. Blood test reveals a serum potassium level of 2.5mmol/L. What is the SINGLE most likely diagnosis?

A 79 year old man has a diagnosis of stage 2 lung cancer. He mobilises with a stick. He drinks and eats well. His recent blood test show the following:

Sodium 122 mmol/L (135-146)

Potassium 3.4 mmol/L (3.5-5.3)

Urea 6.5 mmol/L (25-7.8)

Creatinine 48 mmol/L (45-95)

He remains asymptomatic for hyponatraemia. What is the SINGLE most appropriate management?

A 32 year old man has been repeatedly admitted to the hospital for what was described as anxiety or panic attacks associated with palpitations and sweating. On occasions, he is found to be hypertensive and tremulous. He has been suffering from episodic headaches over the past few months. He smokes 15 cigarettes a day and drinks less than 2 units of alcohol a week. He was started on ramipril 2 months ago by his GP. His pulse rate on admission was 78 beats/minute and blood pressure was 188/104 mmHg. What is the SINGLE most likely diagnosis?

A 24 year old man is admitted to the Emergency Department with abdominal pain and vomiting. His blood and urine results show:

Blood ketones 3.1 mmol/L (<0.6 mmol/L)

Urine ketones ++

Venous pH 7.23 (7.35-7.45)

Venous blood glucose 28 mmol/L (<11 mmol/L)

Bicarbonate 17 mmol/L (22-26 mmol/L)

Sodium 140 mmol/L (135-145)

Potassium 4.8 mmol/L (3.5-5)

What is the SINGLE most appropriate immediate management?

A 55 year old woman complains of worsening fatigue over the past four months. She also suffers from constipation. She describes cold intolerance on most days. She has a BMI of 34 kg/m2. A blood test was requested which shows the following:

Haemoglobin 129 g/L (115-160 g/L)

Thyroid stimulating hormone (TSH) 28.9 mU/L (0.5-5.7)

Free triiodothyronine (T3) 2.2 pmol/L (3.5-6.5)

Free thyroxine (T4) pmol/L 2 (9-18)

Anti-TPO antibodies positive

She has no abnormal palpable masses on her neck. What is the SINGLE most appropriate action?

A 21 year old woman complains of excessive hair growth on her face, chest and back. She reached pubarche before age 8. She has a deep voice. Her menstrual periods are very irregular and infrequent. She also has severe acne on her face. Her BMI is 22 kg/m2. Her blood pressure is 110/75 mmHg. What is the most appropriate biochemical test to perform that will confirm a diagnosis?

A 29 year old woman with a recent history of thyrotoxicosis is brought to the Emergency Department by her husband as she has reduced consciousness and tremors. She complained of palpitations, vomiting, and diarrhoea earlier in the day. Her medical history includes Grave’s disease which she had recently discontinued her anti-thyroid medication. Her pulse rate is 120 beats/minute and she has a temperature of 40.1°C. Which medication is likely to benefit this patient in the acute management of thyroid crisis?

A 44 year old man presents to the Emergency Department with palpitations nausea, vomiting and drowsiness. His ECG shows tall tented T waves and a wide QRS complex His blood results show the following:

Calcium 2.65 mmol/L

Potassium 6.3 mmol/L

Urea 21 mmol/L

Magnesium 0.65 mmol/L

eGFR 41

On viewing his blood results 2 months ago, his previous eGFR was found to be normal. What is the SINGLE most appropriate next step?

A 34 year old vegetarian woman presents with proximal body weakness and pain. When measuring her blood pressure, she develops hand and wrist spasms. Her lab results show the following

Sodium 136 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5)

Urea 10 mmol/L (2.0-7)

Creatinine 80 μmol/L (70-150)

Serum corrected calcium 1.85 mmol/L (2.1-2.6)

Parathyroid hormone (PTH) 12.9 pmol/L (0.8-8.5)

Serum alkaline phosphatase (ALP) 193 U/L (30-150)

Vitamin D 9 nmol/L (60-105)

What is the most appropriate initial treatment?

A 46 year old woman who lives in UK complains of weight gain, constipation and sensitivity to cold. Her pulse is regular at 50 beats/minute. She complains of dry skin. What is the SINGLE most likely underlying mechanism for her condition?

A 70 year old woman presents with an 18 month history of non-specific symptoms, including lethargy, reduced appetite, myalgia, muscle cramps and weight loss. She was diagnosed with polymyalgia rheumatica 4 years ago and has been taking 3 mg once daily over the past 3 years. Prednisolone was tapered off and discontinued 3 months ago. Her blood tests show the following.

Haemoglobin 120 g/L (115-160)

Sodium 135 mmol/L (135-145)

Potassium 4.3 mmol/L (3.5-5.0)

9 am cortisol 220 nmol/L (100-536)

Glucose (fasting) 5 mmol/L (3.5-5.5) Serum urea 5.5 mmol/L (2.0-7)

Serum creatinine 113 μmol/L (70-150) Serum calcium 2.15 mmol/l (2.1-2.6)

Which of the following is the most appropriate investigation to confirm a diagnosis?

A 29 year old woman is referred to the endocrine clinic with a history of hyperthyroidism. She is 25 weeks pregnant. At her first appointment, she is found to have a smooth goitre. She is not taking any medications at present. Her blood results show:

Thyroid stimulating hormone (TSH) 0.2 mU/L (0.5-5.7)

Free thyroxine (T4) pmol/L 58 (9-18)

Thyroid peroxidase (TPO) positive

Her heart rate is 113 beats/minute. What is the SINGLE most appropriate treatment?

A 32 year old smoker presents with double vision on looking upwards. She also complains of pain on eye movement as well as dry eyes most of the day. The eye pain is described as an ache which is worse in the morning. On examination, her eyelids appear to move more slowly than the eyes on looking downwards. There is noticeable swelling of her eyelids. What is the SINGLE most appropriate investigation that would lead to a diagnosis?

A 9 year old boy had glycasuria following an appendectomy. He has no history of diabetes mellitus. A few days later, his glycosuria resolved. What is the SINGLE most appropriate follow-up investigation?

A 43 year old man with type 1 diabetes mellitus is seen in clinic for his diabetic review.

He takes regular insulin to manage his diabetes. His blood pressure is 168/98 mmHg. His blood test and urine test are as follows:

Sodium 138 mmol/L (135-146)

Potassium 3.7 mmol/L (3.5-5.3)

Urea 7.2 mmol/L (25-7.8)

Creatinine 85 mmol/L (45-95)

HbA1c 61 mmol/mol (<48)

eGFR 54 mL/min (>90) – previous eGFR done 3 months ago was 62 mL/min

Urine albumin creatinine ratio (ACR) 76 mg/mmol (<30)

His ACR was repeated and was 77 mg/mmal. What is the SINGLE most appropriate management?

A 24 year old woman attends the GP surgery to discuss the results of her recent blood test. She has a medical history of hypothyroidism and is treated with 50 mcg of levothyroxine daily. She takes the medications every morning without fail. She continues to describe a degree of tiredness and lethargy. Her blood test is seen below:

Haemoglobin 116 g/L (115-160)

Thyroid stimulating hormone (TSH) 8.9 mU/L (0.5-5.7)

Free thyroxine (T4) pmol/L 11 (9-18) HDL cholesterol 1.7 mmol/L (0.9-1.93)

LDL cholesterol 2.1 mmol/L (< 2) Triglycerides 1.5 mmol/L (0.55-1.90)

Total cholesterol 5.3 mmol/L < 5)

What is the SINGLE most appropriate management?

A 45 year old man with diagnosed colon cancer develops increased thirst, and frequent urination. He is also noted to have been losing weight in the last couple of months. His blood test shows a fasting blood glucose of 9 mmol/L. He has a pulse of 70 beats/minute, a blood pressure of 125/80 mmHg and a respiratory rate of 18 breaths/minute. Which medication would likely benefit him?

A 31 year old man is seen in the hypertensive clinic after being referred by his GP for hypertension, tremors, profuse sweating and palpitations. He suffers from intermittent excruciating headaches that are variable occurring several times a week. About 3 to 4 times a week, he suffers from extreme anxiety, becomes short of breath and sweats excessively. His blood pressure was measured at 170/115 mmHg but dropped to 139/92 on standing. What is the SINGLE most likely diagnosis?

A 38 year old woman stopped taking combined oral contraceptive pills 6 months ago and she has been amenorrhoeic since then. She does not take any regular medications. Her pregnancy test is negative. She does not suffer from any headaches or changes in vision. Her recent blood results show:

Follicle-stimulating hormone (FSH) 25 IU/L (<25)

Luteinizing Hormone (LH) 16 IU/L (<84)

Prolactin 540 mU/L (<400)

Liver function, renal function and thyroid function are normal

Her BMI is 24 kg/m2. What is the SINGLE most likely cause?

A 44 year old woman has been feeling more tired over the past few months. A blood test looking for causes of tiredness was requested. Her blood results reveal the following:

Haemoglobin 143 g/L (115-160)

White cell count 8 x 10^9/L (4-11)

Neutrophils 3.1 x 10^9/L (2-7.5)

Platelets 220 x 10^9/L (150-400)

Thyroid-stimulating hormone (TSH): 12.8 mU/L (0.5 – 5.7 mU/L)

Free thyroxine (T4): 11 pmol/L (9-18 pmol/L)

She has no goitre palpable on examination. What is the SINGLE most appropriate next step?

A 23 year old woman presents to the GP surgery with a history of feeling more lethargic over the past few months. She complains of dry skin on her legs. A blood test looking for causes of tiredness was requested. Her blood results reveal the following:

Haemoglobin 123 g/L (115-160)

White cell count 7 x 10^9/L (4-11)

Neutrophils 5.1 x 10^9/L (2-7.5)

Platelets 228 x 10^9/L (150-400)

Thyroid-stimulating hormone (TSH): 9.8 mU/L (0.5-5.7 mU/L)

Free thyroxine (T4): 11 pmol/L (9-18 pmol/L)

A repeated thyroid function test was performed 3 months later which shows:

Thyroid-stimulating hormone (TSH): 8.8 mU/L (0.5-5.7 mU/L)

Free thyroxine (T4): 15 pmol/L (9-18 pmol/L)

She has no goitre palpable on examination. She has been trying to conceive. What is the SINGLE most appropriate next step?

A 28 year old man has an extreme thirst and marked polyuria over the duration of 2 weeks. He urinates more than 3 litres a day of urine. He has to urinate a few times at night which disturbs his sleep. He has suffered from bacterial meningitis a month ago which he was treated as an inpatient. His blood results show the following:

Haemoglobin 141 g/L (130-180)

White cell count 6 x 10^9/L (4-11)

Platelets 380 x 10^9/L (150-400)

Sodium 154 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5)

Creatinine 140 μmol/L (70-150)

eGFR >90 mL/min

Random glucose 5.6 mmol/L

His urine osmolality is low. What is the SINGLE most appropriate test?

A 12 year old boy was admitted 4 days ago to the hospital for management of meningitis. He was started in intravenous fluids and antibiotics. His blood results show the following:

Haemoglobin 131 g/L (130-180)

White cell count 15 x 10^9/L (4-11)

Platelets 350 x 10^9/L (150-400)

Sodium 122 mmol/L (135-145)

Potassium 4.8 mmol/L (3.5-5)

Urea 7 mmol/L (20-7)

Creatinine 144 μmol/L (70-150)

eGFR >90 mL/min

He does not have any muscle cramps, weakness or confusion. He is alert on examination. What is the SINGLE most likely cause of his blood results?

A 28 year old woman attends the clinic complaining of a lump on her anterior neck which she noticed 4 weeks ago. She has had difficulty swallowing over the past few weeks. Examination reveals a 2 cm x 2 cm oval-shaped mass at the level of the hyoid bone. The lump is felt to be hard, and it is not tender on palpation. The lump moves upwards on the protrusion of her tongue. What is the SINGLE most appropriate investigation to perform?

A 27 year old woman presents with tremors, anxiety. She has a history of significant weight loss aver the last 6 months.She has a heart rate of 112 beats/minute. Mild proptosis was seen an examination. What is the SINGLE most likely mechanism that accounts for her symptoms?

A 63 year old diabetic patient on oral hypoglycaemics complains of diarrhoea for the past 3 months. His blood sugar levels have been poorly controlled. He has not changed his diabetic medications for the past year. What is the SINGLE most likely cause for his diarrhoea?

A 32 year old man has frequent headaches and complains of profuse sweating. His headaches are excruciating and can last several hours before subsiding. They occur once or twice a week. During these episodes, he finds his skin flushes red and he begins to sweat profusely. His blood pressure remains high despite having started on an ACE inhibitor. His last blood pressure was recorded as 170/110 mmHg. His pulse is 85 beats/minute. What is the SINGLE most likely diagnosis?

A 55 year old diabetic man attends the GP clinic for his yearly medication review. He has been taking metformin, ramipril and bisoprolol for the past year. His medical history includes heart failure and hypertension. His blood pressure is 135/88 mmHg this visit. His BMI is 30 kg/m2. His blood test which was done a week ago shows the following:

Urea 7 mmol/L (2.0-7 mmol/L)

Creatinine 140 (70-150 μmol/L)

eGFR 65 (greater than 90)

HbA1c 52 mmol/mol (Target less than 48 mmol/mol)

What is the most appropriate action?

A 35 year old man was seen in the GP clinic with headaches and palpitations that started a few weeks ago. He has become very anxious over the past few weeks and starting having a tremor. His clinic blood pressure is 220/130 mmHg and heart rate is 100 beats/minute. He is profusely sweaty in the clinic. What is the SINGLE most likely hormone that is raised?

A 46 year old woman complains of tiredness and lethargy. She has noticed a 8 kg weight gain in the last 3 months and is feeling more sensitivity to cold. She has a pulse rate of 55 beats/minute. What is the SINGLE most likely diagnosis?

A 39 year old woman has been feeling lethargic and tired. She has a blood pressure of 160/90 mmHg despite being on enalapril. Her blood test show:

Haemoglobin 130 g/L

Serum sodium 144 mmol/L

Serum potassium 3.1 mmol/L

What is the SINGLE most likely diagnosis?

A 62 year old man presents with symptoms of polyuria and polydipsia. His past medical history is significant for lung cancer, which is now in remission. His blood results show:

Urea 6.2 mmol/L (20-7)

Creatinine 182 μmol/L (70-150)

Serum calcium (corrected) 3.0 mmol/L (2.1-2.6)

What is the next most appropriate biochemical investigation?

A 55 year old man with a history of type 2 diabetes mellitus has been on a trial of lifestyle modifications for the past 3 months. He is not on any medications for his diabetes. He attends his GP surgery for his recent blood results which show.

Fasting blood glucose 12.3 mmol/L

HbA1c 59 mmol/mol (Target < 48 mmol/mol)

eGFR 28

He has a BMI of 33. What is the SINGLE most appropriate treatment to introduce?

A 33 year old woman has amenorrhoea and galactorrhoea. Her prolactin levels are significantly raised. An MRI shows a 9 mm tumour in the pituitary fossa. What is SINGLE most appropriate management?

A 26 year old woman with diagnosed carcinoma of the bronchus has been receiving steroid treatment for the last several months. She started vomiting and having severe abdominal pain for the past 2 days. She also complains of sudden dizziness in the morning. She also reports he had a few syncopal episodes. The patient’s housemate has said that she went on a trip recently and did not take her medications with her. On examination the patient appears confused and pale, she has a blood pressure of 90/60 mmHg, heart rate of 110 beats/minute, respiratory rate of 29 breaths/minute and a temperature of 38.1°C. What is the SINGLE most likely reason for her symptoms?

A 38 year old man was found unconscious in the hospital hallway. He has a diabetic band which states that he is an insulin-dependent diabetic. On examination, he is breathing and his upper airways are patent. His blood sugar level was taken and reads 1.7 mmol/l. He has no intravenous access. What is the SINGLE most appropriate medication to administer?

A 49 year old man with type 2 diabetes mellitus presents to the GP clinic after an episode of dizziness in the morning. He measured his capillary blood glucose in the morning which was 2.5 mmol/L. He quickly ate a biscuit and had some tea and it repeated it an hour later which his BM read 5 mmol/L. He takes metformin and gliclazide regularly. His HbA1c done a week ago was 43. His renal function is within normal limits. What is the SINGLE most appropriate action?

A 55 year old woman with a history of a right mastectomy 5 years ago for breast cancer is brought into the Emergency Department by her husband as she has been increasingly drowsy over the past 48 hours. He mentions that she has been complaining of increased thirst for the past week. She suffers with depression and has started fluoxetine 4 months ago. What is the SINGLE most likely cause of her symptoms?

A 44 year old woman has retro-orbital headaches, menstrual irregularities and unexplained milk discharge from her nipples. She also has a visual field defect. An MRI reveals a pituitary tumour. What is the SINGLE most likely visual abnormality associated with a pituitary tumour?

A 12 year old boy is clinically obese and is the shortest in his class. His medical history includes having a renal transplant 2 years ago. There are purple striae noticed on his skin. What is the SINGLE most likely diagnosis?

A 40 year old woman presents to the endocrinology clinic after being referred by the GP. She presented to the GP surgery a few weeks ago and complained of feeling excessively tired for the past 2 months. She had also noticed that the skin over her knuckles and knees had taken on a brownish hue. Additionally, she reported that she has intense cravings for salty snacks and found herself reaching for crisps quite often. On assessment in the endocrinology clinic, her buccal mucosa was hyperpigmented, her blood pressure was 92/64 mmHg, and her heart rate was 80 beats/minute. Her blood reports are as follows.

Haemoglobin 110 g/L (115-160)

Sodium 125 mmol/L (135-145)

Potassium 5.5 mmol/L (3.5-5.0)

9 am cortisol 202 nmol/L (100-536)

Which of the following is the most appropriate investigation to confirm a diagnosis?

A 71 year old female had a hip fracture a few months ago. Two years prior to that, she presented with a fracture of her distal radius after falling down the stairs. Her dual- energy X-ray absorptiometry (DEXA) scan results reveal a T-score of -2.8. What is the SINGLE best treatment for this patient?

A 45 year old man was scheduled for an elective hernioplasty to be done as a day case procedure. His past medical history includes type 2 diabetes mellitus diagnosed a year ago. He was advised to try diet and lifestyle modifications first and the patient claims to be following a strict diet and exercise regimen. He is not on any medication. His current body mass index (BMI) is recorded to be 23 kg/m2. He was approved for surgery and the hernioplasty was carried out successfully. Three days following the surgery, he was seen by his GP for a routine diabetic follow up. His blood results show:

Fasting blood sugar 8 mmol/L (3.5-5.5 mmol/L)

Random blood sugar 11 mmol/L (5.0-9.0 mmol/L)

HbA1c 60 mmol/mol (below 42 mmol/mol)

Urinalysis was negative for glucose and ketones

A renal function test was also carried and the values were found to be within normal limits.

What is the SINGLE next best step in the management of this patient?

A 65 year old woman presents with longstanding pain in her legs and hips. She complains of general weakness and finds difficulty rising from a chair. There is proximal muscle weakness on examination. Due to her hip pain, she chooses to stay at home most of the time. Blood tests reveal:

Serum corrected calcium 2.09 mmol/L (2.10-2.60)

Serum alkaline phosphatase (ALP) 230 U/L (30-150)

Serum alanine transferase (ALT) 34 U/L (5-35)

Sodium 138 mmol/L (135-145)

Potassium 3.9 mmol/L (3.5-5) Urea 3 mmol/L (20-7)

Creatinine 89 μmol/L (70-150)

eGFR 90 mL/min (>90)

Erythrocyte sedimentation rate (ESR) 10 mm/hr (<15)

What is the SINGLE most appropriate management?

A 49 year old woman has an incidental finding of her blood results that shows:

Thyroid-stimulating hormone (TSH): 7.8 mU/L (0.5-5.7 mU/L)

Free thyroxine (T4): 11 pmol/L (9-18 pmol/L)

A repeated thyroid function test was performed 3 months later which shows:

Thyroid-stimulating hormone (TSH): 8.8 mU/L (0.5-5.7 mU/L)

Free thyroxine (T4):10 pmol/L (9-18 pmol/L)

She has tested negative for thyroid antibodies. She has no history of previous thyroid surgery. What is the SINGLE most appropriate next step?

A 43 year old man with multiple myeloma attends the outpatient clinic with complaints of thirst, lethargy and frequent urination. He also complains of a 5-day history of constipation. What is the SINGLE most likely biochemical abnormality to be associated with his symptoms?

A 35 year old man with a medical history of type 1 diabetes mellitus presents to the hospital with reduced conscious level and feeling unwell. He has dry mucous membranes and a slow capillary refill. He has a blood pressure of 80/50 mmHg and a pulse rate of 105 beats/minute. What is the SINGLE most appropriate initial investigation?

A 63 year old man who takes spironolactone and ramipril for hypertension and was found to have elevated potassium of 5.8mmol/L on routine blood test while on a day ward. He is otherwise well and has no allergies. An ECG is carried out which is normal. His blood pressure is 119/70 mmHg. What is the SINGLE best initial treatment in light of his potassium levels?

A 26 year old woman comes to the Emergency Department with vomiting, abdominal pain, and tachypnoea. Her breath has a fruity smell. She has a heart rate of 120 beats/minute and a respiratory rate of 30 breaths/minute. Her blood pressure is 100/60 mmHg and oxygen saturation is 95%. Her blood and urine results show:

Blood ketones 3.3 mmol/L (less than 0.6 mmol/L)

Urine ketones +++

Venous pH 7.22 (7.35-7.45)

Venous blood glucose 22 mmol/L (less than 11 mmol/L)

Bicarbonate 18 mmol/L (22-26 mmol/L)

What is the most appropriate immediate management?

A 72 year old man has a mass on his anterior neck which he noticed 3 weeks ago. He has no weight loss and reports no hoarseness of voice. On examination, his thyroid gland has a palpable swelling with an otherwise normal appearance. He has palpable cervical lymph nodes. He was subsequently referred to secondary care for further investigations and management. What is the SINGLE most likely reason for the referral?

A 30 year old woman is admitted to the hospital because of nausea, vomiting and abdominal pain. She has been feeling malaise for the past 2 months. Her past medical history includes asthma which was diagnosed 3 years ago. She takes fluticasone, salbutamol and salmeterol inhalers. Her ECG and abdominal X-ray were unremarkable. Her blood reports are as follows.

Haemoglobin 109 g/L (115-160)

Sadium 128 mmol/L (135-145)

Potassium 5.3 mmol/L (3.5-5.0)

9 am cortisol 223 nmol/L (100-536)

Glucose (fasting) 4 mmol/L (3.5-5.5)

Which of the following is the most appropriate investigation to confirm a diagnosis?

A 33 year old patient has a routine fasting blood glucose of 7.4. He is otherwise well and has no complaints of polydipsia or polyuria. He has no medical issues in the past. What is the SINGLE most appropriate next step in action?

A 75 year old man with a recent diagnosis of prostate cancer has confusion, thirst, lower back pain and abdominal pain. An ECG was performed which showed shortening of QT interval. What is the SINGLE most appropriate investigation?

A 65 year old woman presented to her GP complaining of worsening lower back pain over the last 4 months. Her routine blood test showed the following results:

Sodium 134 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5.0)

Adjusted Calcium 2.1 mmol/L (2.2-2.6)

Phosphate 0.9 mmol/L (0.8-1.4)

Parathyroid hormone (PTH) 70 nmol/L (10-65)

Vitamin D 19 (<25 nmol/L severely deficient)

Serum urea 6.5 mmol/L (2.0-7)

Serum creatinine 99 μmol/L (70-150)

eGFR 90

She works as a bookkeeper in a law firm and has no previous medical history.

What is the most likely cause for the abnormalities in her blood test and the presenting complaint?

A 20 year old woman presents with tiredness, weight loss, increased thirst and increased frequency of going to the washroom over the past 6 months. Her BMI is 19 kg/m2. Her elder brother, father, and paternal grandmother have been diagnosed with diabetes mellitus. Her blood test shows a HbA1c of 65 mmol/mol (<48). She has no ketones found in her urinalysis. What is the SINGLE most appropriate next step in management?

A 22 year old footballer collapses during a game and is brought into A&E by ambulance. During the initial evaluation, his respiratory rate is 14/min and pulse rate is 84 bpm, BP is115/80 mmHg. He is sweating profusely and muttering incomprehensible words. What is the SINGLE most appropriate next course of action?

A 39 year old man has 7 kg unintentional weight loss in the last two months despite having a good appetite. He also complains of palpitations, sweating and diarrhoea. He has a lump in front of his neck which moves on swallowing. What is the SINGLE most appropriate diagnosis?

A 74 year old man with a 6 month history of weight loss and worsening cough. He is a chronic smoker, with a 60 pack-year history. He is brought to the Accident & Emergency department following a fall and confusion. Which electrolyte imbalance is most likely to be found?

A 40 year old male with pre-existing glomerulonephritis deteriorates and presents with oliguria.

Lab results show the following:

Serum K+= 6.9mmol/L

Urea = 13 mmol/L

Creatinine = 342 mmol/L

GFR = 19 mL/h

What is the SINGLE most appropriate initial management?

A 40 year old man has been feeling weak, tired and has been complaining of headaches. He has a blood pressure of 210/100 mmHg. He is not on any medications. His blood test show:

Haemoglobin 130 g/L

Serum sodium 144 mmol/L

Serum potassium 2.9 mmol/L

What is the SINGLE most likely diagnosis?

A 56 year old man was recently started on antihypertensive medication. His recent blood results show:

Sodium 134 mmol/L

Potassium 5.9 mmol/L

Urea 7 mmol/L

Creatinine 111 μmol/L

What is the SINGLE most likely medication responsible for the abnormal results?

A 21 year old man is brought into A&E semi-conscious by his friends. They were at a party and have been drinking alcohol when they found him unconscious in a corner. He is groaning and unable to give any information to the doctors. During the initial evaluation, his respiratory rate is 17/min and pulse rate is 88 bpm, BP is110/70 mmHg. pupils are responsive. His Glasgow Coma Scale (GCS) score is 11/15. What is the SINGLE most appropriate next course of action?

A 33 year old woman has fatigue, irregular menstrual cycles and low moods. Over the past year she has had only 3 menstrual cycles. She has been trying to conceive for the past 2 years. Her LH and FSH levels were found to be low as part of her investigations for infertility. Subsequent tests reveal the following:

Thyroid stimulating hormone (TSH) 0.2 mU/L (0.5-5.7)

Free thyroxine (T4) pmol/L 2 (9-18)

Sodium 122 mmol/L (135-145)

Potassium 5.0 mmol/L (3.5-5)

What is the SINGLE most likely diagnosis?

A 54 year old woman has presented with episodes of abdominal ache, vomiting and postural hypotension. She also has a dark pigmentation of her skin. A diagnosis of Addison’s disease was made. What is the SINGLE most likely electrolyte abnormality expected in this patient?

A 50 year old lady presents with tiredness and weight gain over the last 6 months. She has glucose in her urine and has recently been diagnosed with hypertension.

Investigations were performed and a diagnosis of Cushing’s disease was made. Which of the following is found in Cushing’s disease?

A 41 year old accountant attends the GP surgery for his yearly diabetic review. He currently takes 1g of metformin twice daily. He has a BMI of 33 kg/m2. He remains asymptomatic. His blood pressure is 120/80 mmHg. He is a non smoker and does not drink alcohol. His recent blood results show the following:

HbA1c 58 mmol/mol (<48)

His previous HbA1c 6 months ago was 54 mmol/mol. A renal function test was also carried and the values were found to be within normal limits.

What is the SINGLE next best step in the management of this patient

A 28 year old woman attends the GP surgery with ongoing symptoms of palpitation and tremors of the hands. These symptoms started a month ago. She delivered her first child vaginally 3 months ago and is still breastfeeding. Her GP requested some blood test which results are below.

Thyroid stimulating hormone (TSH) 0.2 (0.5-5.7 mU/L)

Free thyroxine (T4) 48 (9-18 pmol/L)

Free triiodothyronine (T3) 15 (3.5-6.5 pmol/L)

She tests positive for thyroid peroxidase antibodies and she has a normal ESR. Her heart rate is 100 beats/minute. What is the most appropriate action?

A 48 year old woman complains of fatigue and easy skin bruising. She has been put on 15 kg over the past 8 weeks and now weighs 105 kg. She notices that she is constantly hungry. She feels weak and finds it increasingly difficult to climb stairs or lift weights in the gym. She has no previous medical issues. She does not drink any alcohol. On examination, there is a weakness in shoulder abduction and hip flexion. Her blood pressure is 165/95 mmHg. Recent blood results are shown below:

Haemoglobin 135 g/L (115-160 g/L)

Sodium 149 mmol/L (135-145 mmol/L)

Potassium 3.1 mmol/L (3.5-5.0 mmol/L)

What is the SINGLE most appropriate initial investigation?

A 71 year old woman presents with longstanding pain in her legs and back. Her past medical history is significant for a vertebral compression fracture 12 months ago and a dairy allergy. She reports not being able to leave the house much due to the pain. Blood tests reveal:

Serum calcium 1.90 mmol/L (2.20-2.60)

Serum phosphate 0.69 mmol/L (0.80-1.45)

Serum PTH 5.5 pmol/L (0.9-5.4)

Serum alkaline phosphatase 115 U/L (45-105)

What is the most likely diagnosis?

A 72 year old woman has two fainting episodes over the past 3 days. Her daughter has brought her to the Emergency Department because she is worried about the two events. She was sitting down when she collapsed and did not injure herself. She feels tired, weak and dehydrated. She has no relevant medical history. She eats a balanced healthy diet. Her standing blood pressure is 130/80 mmHg and lying blood pressure is 135/85 mmHg. Her ECG shows normal sinus rhythm. Her capillary blood glucose is recorded as 5 mmol/L. Her blood results show.

Haemoglobin 115 g/L(115-160 g/L)

White cell count (WCC) (total) 12 x 10^9 /L (4-11 x 10°/L)

Sodium 133 mmol/L (135-145 mmol/L)

Potassium 2.8 mmol/L (3.5-5.0 mmol/L)

Urea 11 mmol/L (2.0-7 mmol/L)

Creatinine 140 μmol/L (70-150 μmol/L)

Bicarbonate 33 mmol/L (22-26 mmol/L)

eGFR 85 (>90)

Intravenous normal saline was started in the department. What is the next most appropriate management?

A 30 year old man has frequent episodic headaches with palpitations for the past several months. He suffers from anxiety and has the occasional tremor on both his hands. His blood pressure was recorded as high on multiple occasions. His last blood pressure was found to be 160/110 mmHg in the clinic but a 24-hour ambulatory monitoring shows a peak of 202/130 mmHg with an average of 170/110 mmHg. A 24-hour urinary metanephrine collection was high. What is the SINGLE most likely diagnosis?

A 64 year old type 2 diabetic man attends the GP clinic for his yearly medication review. He has been taking metformin, enalapril and bisoprolol for the past year. His medical history includes heart failure and hypertension. He has been recently diagnosed with heart failure with reduced ejection fraction 5 months ago. His blood pressure is 125/88 mmHg this visit. His BMI is 29 kg/m2. His blood test which was done a week ago shows the following:

Urea 6 mmol/L (20-7 mmol/L)

Creatinine 140 (70-150 μmol/L)

eGFR 90 (>90)

HbA1c 54 mmol/mol (Target <48 mmol/mol)

What is the most appropriate action?

A 36 year old man was involved in a road traffic accident 2 weeks ago. There was significant trauma to his head. He developed significant thirst and increased urination a few days after the accident. He drinks roughly 5 litres of fluid a day. He has to urinate a few times at night. His blood test is seen below.

Sodium 154 mmol/L (135-145)

Creatinine 80 μmol/L (70-150)

eGFR >90 mL/min

Which investigation would likely be abnormal?

A 70 year old man has polyuria and polydipsia. His last two random blood sugar levels were 8 and 9 mmol/L. His blood results show a cholesterol level of 5.8. He has a blood pressure of 135/80 mmHg. He is also noted to have microalbuminuria seen on his urine test. His regular medications include metformin. What is the SINGLE most appropriate medications to be added on?

A 4 year old child is brought to the emergency department by his mother with complaints of vomiting for the past 4 days. On examination, he has clinical signs of mild to moderate dehydration. What is his venous blood gas profile likely to show?

A 65 year old woman presented with visible haematuria and left flank pain. She has recently retired from her job as an assistant manager at a superstore. She has no past medical history. Her biochemistry results are shown below:

Serum calcium 2.95 mmol/l (2.1-2.6)

Parathyroid hormone 13 pmol/L (<0.8-8.5 pmol/L)

The Urology team had asked for an Endocrinology review. What should be the most appropriate definitive treatment?

A 38 year old male was rushed to Accident & Emergency after his wife found him unconscious on the floor of his home. Initial evaluation of the patient revealed severe dehydration, hypotension, tachycardia and a body temperature of 39°C. He was started on intravenous normal saline. Blood tests done in A&E revealed hyponatraemia, hyperkalaemia and hypoglycaemia. His wife mentions that he had been diagnosed with Addison’s disease a few years ago. What is the SINGLE other treatment that you should give this patient?

A 39 year old lady presents with gradually worsening headaches, visual disturbance, and lack of energy. MRI shows a 15mm tumour in the pituitary fossa. She has been on cabergoline for treatment of her prolactinoma but has not had any response. What is SINGLE most appropriate management?

A 65 year old man is feeling unwell after a recent myocardial infarction 3 weeks ago. He was found outside unconscious by his carers in the morning who brought him to the Emergency Department. He has no recollection of the events that happened in the morning. On examination, his mucous membranes look dry. Coarse crackles can be heard on his left lower lung on auscultation. He has a temperature of 36°C, blood pressure of 101/68 mmHg and a heart rate of 101 beats/minute. He was catheterised in the department and his urinalysis reveals the following:

Blood++

Protein ++

Ketones +

A recent ECG of the patient shows widening of the QRS complex and tall-tented T wave. His blood results show:

Sodium 136 mmol/L (135-145)

Potassium 6.2 mmol/L (3.5-5)

Urea 5 mmol/L (20-7)

Creatinine 90 μmol/L (70-150)

What is the SINGLE most appropriate management?

A 21 year old lady has unexplained milk secretion from both her nipples over the past few weeks. Her last menstrual period was 6 months ago and prior to that, she has been having very irregular menstrual cycles. She has done a pregnancy test at home which was negative. She has no relevant past medical history and does not take any regular medications. She has no palpable masses on her breast. What is the SINGLE most appropriate hormone to measure?

A 75 year old woman with type 1 diabetes mellitus has a blood test that shows the following:

Haemoglobin 153 g/L (115-160)

White cell count 7 x 10^9 /L (4-11)

Neutrophils 5.5 x 10^9 /L (2-7.5)

Platelets 290 x 10^9 /L (150-400)

Thyroid-stimulating hormone (TSH): 11.8 mU/L (0.5-5.7 mU/L)

Free thyroxine (T4): 10 pmol/L (9-18 pmol/L)

She complains of feeling more fatigued throughout the day over the past few months.

She has no goitre palpable on examination. What is the SINGLE most appropriate next step?

A 38 year old lady was admitted with severe abdominal pain and diarrhoea. On examination, hyperpigmentation is noticed at the palmar creases and buccal mucosa. She has muscle cramps and joint pain. Her blood pressure is 79/50 mmHg. Her blood results show the following:

Sodium 129 mmol/L (135-145)

Potassium 5.4 mmol/L (3.5-5.0)

Random plasma glucose 3 mmol/L

What is the SINGLE most likely diagnosis?

A 44 year old woman has recently undergone surgery for a fractured left hip. Her blood tests show the following:

Bilirubin 16 micromol/L (3-17 micromol/L)

Alkaline phosphatase 338 U/L (40-130 U/L)

Aspartate aminotransferase 21 U/L (5-35 U/L)

Alanine aminotransferase 37 U/L (5-35 U/L)

Potassium 3.9 mmol/L (3.5-5.0 mmol/L)

Corrected calcium 2.0 mmol/L (2.2-2.6 mmol/L)

Phosphate 0.6 mmol/L (0.8-1.4 mmol/L)

What is the SINGLE most likely diagnosis?

A 38 year old woman has a neck mass that has been progressively increasing over the period of a year. She has a sensation of choking when she lies flat. Examination findings are consistent with a thyroid mass. An ultrasound scan revealed a multinodular goitre a few months ago. A radioisotope scan revealed a cold nodule. Following the scan, fine needle aspiration of the dominant nodule was performed and cytology showed no evidence of malignancy. She denies any symptoms of thyroid dysfunction. Her recent blood test shows the following:

Thyroid stimulating hormone (TSH) 4.2 mU/L (0.5-5.7)

Free thyroxine (T4) pmol/L 15 (9-18)

She has a temperature of 36.7°C, heart rate of 70 beats/minute, blood pressure of 100/70 mmHg, respiratory rate of 15 breaths/minute and an oxygen saturation of 98%. A CT scan shows slight tracheal compression. What is the SINGLE most appropriate management?

A 58 year old woman has tiredness and diarrhoea for the last few weeks. She has noticed that her skin looks tanned. She describes dizziness on standing up and recently started feeling nauseous. What is the SINGLE most likely electrolyte abnormality to be found?

An 18 year old man has extreme thirst and polyuria. 6 months ago he had a significant head injury as the result of a road traffic accident. A diagnosis of diabetes insipidus is suspected. What is the SINGLE most likely laboratory findings after fluid deprivation before the administration of desmopressin? (normal plasma osmolality 275-295 mosmol/kg and normal urine osmolality is 300-900 masmal/kg)

A 45 year old woman presented to the Emergency Department with the complaint of nausea and vomiting for one week. She also reported a three month history of progressively worsening fatigue. The patient had been previously very active as a swimming instructor but, for the past three months, had been unable to carry out her job because of a lack of energy. She also reported a poor appetite for the preceding months and had lost approximately three kilograms of body weight during that time as well. One week prior to admission, she had also started feeling dizzy and described the room as spinning around her when she stood for long periods of time. Her blood pressure was measured on admission and showed 140/80 mmHg (lying down) and 110/60 mmHg (standing up). Blood tests were also done and the results are as follows:

Sodium 124 mmol/L (135-145)

Potassium 6.5 mmol/L (3.5-5)

Urea 7.9 mmol/L (2.0-7)

Creatinine 100 μmol/L (70-150)

What is the SINGLE most common cause of her pathology in the United Kingdom?

A 9 year old girl who is known to have type 1 diabetes mellitus presents with drowsiness and deep breathing. Her blood glucose is 18 mmol/L. She has a blood pressure of 90/60 mmHg and her mucous membranes are dry. What is the SINGLE most appropriate next step?

A 39 year old man has complains of galactorrhoea over the past month. On examination of his visual fields, a bitemporal hemianopia was noted. What is the SINGLE most likely diagnosis?

A 41 year old known type 1 diabetic an insulin is brought in by the paramedics to the Emergency Department. She was found unconscious on the floor by her son. She was found to have a capillary blood glucose of 1.8 mmol/L by the paramedics and was administered glucagon intramuscularly. She has a Glasgow Coma Scale of 3. The anaesthetist is present to secure her airways. What is the SINGLE most appropriate medication to administer?

A 45 year old lady complains of milk discharge from her nipples over the past 2 days. She has been having a low sex drive over the past few months which she finds extremely abnormal. Further history reveals weight gain, low moods and fatigue which have been ongoing for the past year. Her last menstrual cycle was 2 months ago however she is not concerned as she has been having irregular cycles for the past 2 years. She takes lactulose for constipation. Her serum prolactin levels are 586 mU/L (<440). What is the SINGLE most likely cause of her hyperprolactinaemia?

A 48 year old diabetic lorry driver attends the GP clinic for his yearly medication review. He takes a total of 1 g of metformin in a day as that is the maximum he can tolerate. His blood results a week before his review shows the following

Urea 5 mmol/L (2.0-7 mmol/L)

Creatinine 140 (70-150 μmol/L)

eGFR 50 (>90)

HbA1c 58 mmol/mol (Target < 48 mmol/mol)

His blood pressure is 133/88 mmHg this visit. His BMI is 32 kg/m2. What is the SINGLE most appropriate action?

A 29 year old male comes to clinic with a swollen, painful right wrist joints. On further questioning, he gives a history of noticing a change in his shoe size. His other complains also include constipation, feeling cold and needing more warm clothes to keep him warm. On examination, his skin is found to be dry and his right wrist is erythematous and tender to touch. What is the SINGLE most likely diagnosis?

A 44 year old lady has just recovered from an upper respiratory tract infection a week aga. She feels her heart racing and has increased perspiration. On examination, her thyroid gland is tender but there is no significant enlargement. Her blood tests show.

Free thyroxine (T4) 48 pmol/L (9-18 pmol/L)

Free triiodothyronine (T3) 15 pmol/L (3.5-65 pmol/L)

Thyroid stimulating hormone (TSH) 0.1 mU/L (0.5-5.7 mU/L)

Thyroid antibodies negative

What is the SINGLE most likely diagnosis?

A 51 year old man presents to the medical out-patient clinic with the complaint of difficulty in climbing up stairs. He has been having these symptoms for a few months and has complained to his general practitioner before of diffuse muscular aches in the limbs and back. He describes difficulty in getting up from a seated position and general weakness of his quadriceps. He has a poor diet and drinks about 3-4 unit of alcohol a week. He gives a history that he does not go out much. He takes oral steroids during his COPD exacerbations which usually occurs three times a year. A full blood count, urea and electrolytes and a liver function test were done, and they show

Haemoglobin: 13.2 g/dL

Platelets: 220 x 10^9 /L

White cell count: 5.8 x 109/L

Sodium: 138 mmol/L

Potassium: 4.1 mmol/L

Bilirubin: 13 μmol/L

Alanine transferase (ALT): 24 U/L

Aspartate transaminase (AST): 19 U/L

Alkaline phosphatase (ALP): 391 U/L

Gamma glutamyl transferase (GT): 34 u/L Creatine kinase: 192 U/L

What is the SINGLE most likely diagnosis?

A 31 year old woman has 9 kg unintentional weight loss in the last three months despite having a good appetite. She has also not had her menstrual periods during these three months. She usually has a 28-day menstrual cycle and has not missed one for the past 10 years. She feels more sweaty than usual. What is the SINGLE most likely diagnosis?

A 58 year old man who is known to have diabetes mellitus presents to the hospital with drowsiness, blurred vision, tremors, fatigue and confusion. On examination, he is excessively sweaty. Which SINGLE investigations should be done initially to help with further management?

A 45 year old woman has lost weight 12 kg over the past half year. She has also noticed episodes where she feels her heart beat beating rapidly. She has a regular pulse rate of 90 bpm. Her ECG shows sinus rhythm. What is the SINGLE most appropriate investigation to be performed?

A 42 year old woman complains of tingling, numbness, paraesthesia, and involuntary spasm of the upper extremities. She also has perioral numbness. She has undergone a thyroidectomy for thyroid carcinoma a week ago. What is SINGLE most likely diagnosis?

A 47 year old diabetic patient has been taking metformin 850 mg twice daily for 6 months. He had a myocardial infarction 2 years ago and has recently been diagnosed with heart failure. His BMI is 34 kg/m2, blood pressure is 123/87 mmHg. He is a smoker and drinks alcohol occasionally.

HbA1c 59 mmol/mol (<48)

Urea 5.0 mmol/L (0.8-5.5)

Creatinine 70 micromol/L (21-75)

eGFR 93mL/min (>90)

What is the SINGLE most appropriate medication to add?

A 33 year old woman complains of tiredness, lethargy and constipation for the past 12 months. On inspection, she has dry coarse skin, hair loss and cold peripheries. Her blood tests show the following:

Haemoglobin 129 g/L (115-160 g/L)

Thyroid stimulating hormone (TSH) 23.9 mU/L (0.5-5.7)

Free triiodothyronine (T3) 1.6 pmol/L (3.5-6.5)

Free thyroxine (T4) pmol/L 3 (9-18)

What is the SINGLE most likely diagnosis?

A 52 year old woman presents with a painless swelling on the right side of her neck. She initially noticed it 6 months ago since which, it has gradually enlarged. She reports feeling warm and sweaty at times and complains of passing loose stools on and off aver the past 2 months. Occasionally, she feels her heart beating rapidly and finds it distressing. On examination, the swelling appears to involve the right lobe of the thyroid gland. Her blood results show the following:

Haemoglobin 120 g/L (115-160)

Thyroid stimulating hormone 0.1 mU/L (0.5-5.7)

Free T4 30 pmol/L (9-18)

Free T3 18 pmol/L (3.5-6.5)

TPO antibody negative

TSH receptor antibody negative

An isotope scan reveals increased radioactive iodine uptake in an isolated region of the right labe of the thyroid gland and is low in the rest. Which of the following is the single most likely diagnosis?

A 42 year old lady has unexplained milk secretion from her nipples. Her last menstrual period was 6 months ago and prior to that, she has been having very irregular menstrual cycles. She is sexually active but states that recently she is experiencing a loss of libido. She believes this to be due to the painful intercourse she has. For the past few months, she has noticed excessive facial hair growth. She is not on any medications. What is the SINGLE most likely diagnosis?

A 40 year old man presents complaining of needing to drink excessive amounts of water and having to urinate frequently over the past week. He has not lost any weight and otherwise feels well in himself. Upon further questioning, he reports that he had a motorbike accident a few weeks ago involving an injury to his head; however, after being checked over by paramedics at the scene he was not admitted to the hospital. Blood tests reveal

Haemoglobin 142 g/L (130-180)

Platelet count 201 x 10^9/L (150-400)

White cell count 5.0 x 10^9/L (4.0-11.0)

Serum sodium 149 mmol/L (135-145)

Serum potassium 3.6 mmol/L (3.5-5)

Serum urea 6.1 mmol/l (2.0-7)

Serum creatinine 81 μmol/l (70-150)

HbA1c 32 mmol/mol (20-42)

What is the most likely diagnosis?

A 34 year old woman presents with truncal obesity, easy bruising, hyperglycemia and depression. She has a blood pressure of 165/95 mmHg. Cushing’s syndrome is suspected. Which of the following investigations will be most helpful in localising the cause of Cushing’s syndrome?

A 44 year old man is extremely thirsty despite excessive drinking. Diabetes mellitus and renal failure has been ruled out and a diagnosis of diabetes insipidus is suspected. Fluid deprivation test and an assessment of response to vasopressin was done which was consistent with central diabetes insipidus. What is the SINGLE most likely laboratory finding that lead to the conclusion?

A 32 year old woman with headaches and lethargy has hypertension. A recent blood test shows a serum potassium of 29 mmol/l. What is the SINGLE most appropriate hormone test to order?

A 59 year old woman has constipation, fatigue and body aches. She has had a recent episode of renal colic a month ago. She had a colles fracture 3 months ago. Her blood results show the following:

Haemoglobin 155 g/L (130-180)

White cell count 10 x 109/L (4-11)

Platelets 250 x 109/L (150-400)

eGFR 90 (>90)

Corrected calcium 2.98mmol/L (2.1-2.6 mmol/L)

Vitamin D 59 nmol/L (sufficient if >50 nnoml/L)

Parathyroid hormone 8.9 pmol/L (<0.8-8.5 pmol/L) Phosphate 0.6mmol/L (0.8-1.4 mmol/L)

Her previous corrected calcium level a month ago was 2.72 mmol/L. What is the most appropriate action?

A 62 year old man had a bowel resection 3 days ago for colorectal cancer. His urine output has been low since the procedure and he is now becoming breathless. He has a blood pressure of 130/95 mmHg. On auscultation, he has crackles at both lung bases and on palpation, he has sacral oedema. His blood tests show.

Haemoglobin 109 g/L (130-180)

Serum urea 50.5 mmol/L (2.0-7)

Serum creatinine 603 μmol/L (70-150)

Serum potassium 6.72 mmol/l (3.5-5)

What is the SINGLE most appropriate immediate management?

A 33 year old woman has been having lethargy and weight gain for the past 3 months. She had a vaginal delivery 6 months ago which was complicated by a major post-partum haemorrhage. She had to feed her child formula milk as she was not able to lactate. Her menstrual cycles have not resumed. Injury to which anatomical structure is likely to result in her symptoms?

A 31 year old man has an extreme thirst and marked polyuria over the duration of 6 weeks. A 24-hour urine collection was recorded at 3.5 litres. His blood results show the following:

Haemoglobin 148 g/L (130-180)

White cell count 7 x 10^9 /L (4-11)

Platelets 280 x 10^9 /L (150-400)

Sodium 146 mmol/L (135-145) Potassium 3.9 mmol/L (3.5-5)

Creatinine 80 μmol/L (70-150)

eGFR >90 mL/min

Random glucose 5.9 mmol/L

What is the SINGLE most appropriate initial test?

A 55 year old man with a 4 year history feeling thirsty and urinating more often than usual presents with a deep painless ulcer on the heel. He also has a history of unexplained weight loss and feels tired all the time. What is the SINGLE most appropriate investigation?

A 33 year old woman complains of tiredness and lethargy. She has noticed a 10 kg weight gain in the last 4 months and is feeling more sensitive to cold. She describes having very heavy menstrual bleeding over the past few months, although they are regular. What is the SINGLE most likely diagnosis?

A 35 year old man has been having low libido and erectile dysfunction over the past 8 months. He has a normal development of sexual characteristics. He is a non-smoker. His blood test shows the following:

HbA1c 41 mmol/mol (<48)

Lipid profile normal

Testosterone levels 3 nmol/L (10-25)

Prolactin levels 5100 mU/L (<350)

A magnetic resonance imaging (MRI) of his pituitary gland shows evidence of a microadenoma. What is the SINGLE most appropriate management?

A 37 year old male presents to Accident & Emergency (A&E) with the complaint of weakness, nausea and vomiting for four days. He also reports a poor appetite and describes seven kilograms of unintentional weight loss during a period of four weeks. He also complains of muscle aches and joint pains and says that he just feels awful in general. Physical examination of the patient reveals hyperpigmentation of his buccal mucosa and lips. His observations are as follows:

Blood pressure 137/79 mmHg (lying down); 108/62 mmHg (standing up)

A heart rate of 89 beats per minute

Temperature 37.9 °C

Blood tests were also done and the results are as follows:

Sodium 120 mmol/L

Potassium 6.8 mmol/L Urea 7.7 mmol/L

Creatinine 102 μmol/L

What is the SINGLE most likely hormone that is deficient in this patient?

A 58 year old with multiple myeloma diagnosed 3 years ago is admitted in the hospital for rapid confusion and lethargy over the last few days. Her blood results show the following:

Haemoglobin 80 g/L (115-160 g/L)

White cell count (WCC) (total) 13 x 10^9 /L (4-11 x 10^9 /L)

CRP 101 mg/L (less than 10 mg/L)

Urea 10 mmol/L (2.0-7 mmol/L)

Sodium 134 mmol/L (135-145 mmol/L)

Potassium 4.5 mmol/L (3.5-5.0 mmol/L)

Creatinine 135 μmol/L (70-150 μmol/L)

eGFR greater than 60

Alanine transferase (ALT) 34 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 150 U/L (30-150 U/L)

Calcium (Total) 3.4 mmol/L (2.1-2.6 mmol/L)

Thyroid stimulating hormone (TSH) 1 mU/L (0.5-5.7 mU/L)

Intravenous fluids were started. What is the SINGLE next most appropriate management?

A 30 year old woman complains of decreased appetite and weight gain. She has been having irregular, infrequent periods in the last 10 months. She also feels tired and lethargic majority of the day. On inspection, she has a dry coarse skin. What is the SINGLE most likely diagnosis?

A 45 year old lady presents with diarrhoea, vomiting, and severe abdominal pain. Examination reveals that her skin is hyperpigmented especially at areas of skin creases. Her blood pressure is 70/55 mmHg. A venous blood gas reveals metabolic acidosis. What is the SINGLE most likely electrolyte abnormality to be found?

A 9 year old boy during operation and immediately after showed glycosuria. A day later his urinalysis was normal. What is the SINGLE most likely diagnosis?

A 32 year old man has recently had an appendectomy performed. His post-op blood results return with the following values:

Glucose 4.5 mmol/L

Sodium 129 mmol/L

Potassium 5.3 mmol/L

What is the SINGLE most appropriate management?

A 29 year old woman attends the Emergency Department with complaints of abdominal pain, vomiting, tremor and palpitations. For the past 7 days, she has been coughing. feeling warmer and complaining of excessive sweating. Her medical history includes a taxic multi-nodular goitre. Her heart rate is 154 beats/minute and has an irregular rhythm. An ECG shows atrial fibrillation. Her temperature is 39.1°C. On examination, she is agitated and mildly confused with a Glasgow Coma Scale of 12/15. Broad spectrum antibiotics are started. What is the SINGLE most appropriate management for her palpitations?

A 44 year old woman with Addison’s disease attends the hot clinic with a history of a persistent dry cough and fever for the past 3 weeks. She feels tired and sleepy. She takes regular hydrocortisone and fludrocortisone. Her heart rate is 90 beats/minute, respiratory rate is 22 breaths/minute, temperature is 38.5°C, oxygen saturation is 98% and her blood pressure is 120/80 mmHg. COVID-19 is suspected. What is the SINGLE most appropriate advice?

A 67 year old male is urinating more than usual, particularly at night. He recently is feeling tired most of the time. He has a BMI of 33. His urine dipstick tested negative for nitrates but was positive for glucose. What is the SINGLE most appropriate next investigation?

A 56 year old man attends the GP clinic for his routine medication review. His medical history includes type 2 diabetes mellitus. He takes metformin 850 mg twice a day and gliclazide 40 mg once a day. He had a clinic blood pressure of 150/88 mmHg a month ago and was asked to do an ambulatory blood pressure reading which the daytime average results are 134/84 mmHg. His last blood results a week ago show the following:

Haemoglobin 137 g/L (130-180)

Urea 3 mmol/L (20-7)

Creatinine 71 μmol/L (70-150)

eGFR >90 mL/min

HbA1c 53 mmol/mol

What is the SINGLE most appropriate action?

A 33 year old woman complains of fatigue and proximal muscle weakness. She has noticed purple strise on her abdomen which has become more prominent over the past few months. The creases of her skin are becoming more hyperpigmented especially at her palms. She has been increasing in weight. Recent blood results are shown below:

Haemoglobin 130 g/L (115-160 g/L)

Sodium 141 mmol/L (135-145 mmol/L)

Potassium 2.9 mmol/L (3.5-5.0 mmol/L)

Random morning serum cortisol levels high

What is the next most appropriate investigation?

A 42 year old ambulance driver attends the GP surgery for his yearly diabetic review. He currently takes 1g of metformin twice daily. He has a BMI of 31 kg/m2. He remains asymptomatic. His blood pressure is 120/80 mmHg. He is a smoker. He exercises for 30 minutes once a week. His recent blood results show the following:

HbA1c 58 mmol/mol (<48)

A renal function test was also carried and the values were found to be within normal limits.

What is the SINGLE next best step in the management of this patient?

A 33 year old woman is seen in the endocrinology clinic following a referral from the GP for hyperthyroidism. She complains of worsening palpitations, flushing, insomnia and heat intolerance. She has lost 5 kg over the past 3 months. Clinical examination reveals some evidence of Graves’s ophthalmopathy with minor lid retraction. She has a fine tremor. She is a smaker. Her blood test which was done the day before shows the following:

TSH < 0.01mIU/L

Free T4 35 pmol/L (9-18 pmol/L)

Free T3 22 pmol/L (3.5-6.5 pmol/L)

She is already on propranolol for symptomatic relief. She has a heart rate of 90 beats/minute and a temperature of 36.5°C. What is the SINGLE most appropriate medication for this patient?

A 28 year old woman complains of tiredness, lethargy, and intolerance to cold. She has a history of Addison’s disease. Her skin looks dry on examination. She has been having infrequent periods in the one year and her last menstrual period was 3 months ago. What is the SINGLE most likely diagnosis?

An 88 year old woman who fractured her right hip due to a fall is reviewed by the Elderly Care Medicine team after her hip-replacement surgery on the ward. She lives in a nursing home and her past medical history includes Alzheimer’s dementia, hypertension, atrial fibrillation, asthma and type 2 diabetes. The Elderly Care Medicine team is formulating a management plan regarding her blood test results:

Serum calcium 2.75 mmol/l (2.1-2.6)

Serum alkaline phosphatase (ALP) 145 U/L (30-150)

Parathyroid hormone 16 pmol/L (<0.8-8.5 pmol/L)

What should be the most appropriate therapeutic management to address her underlying condition?

A 6 week old baby boy attends the Emergency Department appearing extremely unwell. Mucous membranes are dry on examination with sunken eyes and sunken fontanelles. Skin turgor was reduced. His blood tests show sodium levels at 124 mmol/L and potassium levels at 2.8 mmol/L. What is the SINGLE most appropriate initial management?

A 49 year old man with a diagnosis of squamous cell carcinoma of the lung is brought to the Accidents & Emergency Department by his wife as he is confused and lethargic. He complains of increasing weakness over the past few days. His wife is especially concerned as he has been having repeated falls over the past few days. His blood tests show.

Sodium 149 mmol/l

Calcium 3.2 mmol/1

Potassium 4.5 mmol/l

Urea 7 mmol/L

Creatinine 190 μmol/L

What is the SINGLE most appropriate initial step?

A 24 year old woman presents to the GP surgery with increased thirst and increased frequency of urination. Her paternal grandfather and father bath were diagnosed with diabetes mellitus. Her BMI is 29 kg/m2. Her blood test shows a HbA1c of 60 mmol/mol ( < 48) and a fasting blood Glucose of 10 mmol/L (<7). What is the SINGLE most appropriate management?

A 47 year old man attends the Emergency Department with abdominal pain, vomiting and extreme lethargy. He has had persistent diarrhoea for the past few days. He has a medical history of type 2 diabetes mellitus and hypertension. His regular medications include metformin, canagliflozin and enalapril. His respiratory rate is 30 breaths/minute and his heart rate is 105 beats/minute. The records of his previous HbA1c a month ago show a value of 70 mmol/mol (<48). His random capillary glucose in the department is 10 mmol/L (<11.1). What is the SINGLE most appropriate investigation?

A 33 year old man has attended the GP surgery as he started having white discharge from his nipples yesterday. On further questioning, he states that he has been having difficulty having sexual intercourse with his partner but refuses to describe the problem further. What is the SINGLE most likely diagnosis?

A 43 year old woman is concerned about diabetes mellitus. Her father suffers from type 2 diabetes mellitus. She was screened for diabetes and her fasting glucose level was measured at 7.7 mmol/L. She is asymptomatic. Her BMI is 34 kg/m2. She exercises regularly and has a good diet. What is the SINGLE most appropriate action?

A 68 year old man with type 2 diabetes mellitus and advanced gastric carcinoma is admitted to the hospital because he fell unconscious due to hypoglycaemia. He was managed in the Emergency Department initially with intravenous glucose and has now gained consciousness. He takes metformin and a long-acting insulin twice a day. He has not been eating for the past few days due to lack of appetite and weakness. He is still able to take his medications orally with sips of water. A recent blood test shows an HbA1c level of 59 mmol/mal. He is not for active treatments for his gastric cancer. What is the SINGLE most appropriate action?

A 33 year old woman develops sweating, tremors, malaise and weight loss over the past month. She complains of pain over the thyroid and her lower jaw. Heart sounds on auscultation are found to be normal with no added sounds. Her heart rate is 120 beats/minute. An ECG has been performed and is reported as normal. Her thyroid function test shows the following:

Free thyroxine (T4) 44 pmol/L (9-18 pmol/L)

Thyroid stimulating hormone (TSH) 0.3 mU/L (0.5-5.7 mU/L)

A radioactive iodine uptake test shows depressed radionuclide uptake. Which medication would likely benefit her?

A 28 year old woman presented to her GP with the complaint of amenorrhoea. On further questioning, she reveals that her last menstrual period was approximately twelve months ago and that she has not had a period since. Her menarche was at the age of twelve years. She reports no symptoms regarding the halt of her menses but claims that her menses have always been rather “light”. She has never had any children and does not think that she could be pregnant as she is not in a current relationship. She has lost 2.3 kilograms (around 5 pounds) of body weight over the past three months and reports a two week history of unilateral foot pain. She is a professional athlete and is currently training hard for the 10km long distance race in the Olympics. She typically runs around twelve kilometres per day, at least five times per week. She has a very healthy lifestyle and does not smoke or drink alcohol. On physical examination, her body mass index is 19 kg/m2. There is dull pain on palpation along the forth and fifth metatarsal of her left foot. The physical examination was otherwise normal. A blood sample was taken from the patient and her results are as follows:

Follicle stimulating hormone (FSH) 10 U/L

Luteinizing hormone (LH) S U/L

Prolactin 750 mU/L

Oestradiol 120 pmol/L

What is the SINGLE most likely diagnosis for this patient?

A 31 year old man has profuse sweating, palpitations, headaches, flushing and hypertension. He was diagnosed with phaeochromocytoma and is to have a surgical removal of the tumour in a week. What is the SINGLE most appropriate initial medication to prescribe?

A 49 year old man undergoes a NHS Health Check. His fasting glucose level was measured at 7.7 mmol/L. His renal function is normal. He is a known hypertensive and currently takes ramipril daily. His BMI is 29 kg/m2. His blood pressure in the clinic is 125/84 mmHg. He does not complain of polydipsia, polyuria or blurred vision. What is the SINGLE most appropriate action?

A 35 year old woman complains of worsening fatigue over the past few months. Her medical history includes type 2 diabetes mellitus, hypothyroidism and iron deficiency anaemia. She takes 50 mcg of levothyroxine once daily, 500mg of metformin once daily and ferrous sulphate 200 mg once a day. She has a BMI of 24 kg/m2. She takes her levothyroxine in the morning and her ferrous sulphate in the evening. A blood test was requested which shows the following:

Haemoglobin 120 g/L (115-160 g/L)

TSH 9.1 mU/L (0.5-5.7 mU/L)

Free thyroxine (T4) 4 pmol/L (9-18 pmol/L)

HbA1c 47 mmol/mol ( < 42 mmol/mal)

What is the SINGLE most appropriate action?

A 41 year old woman has been having palpitations over the past few weeks. She has had a 3 kg unintentional weight loss in the last 4 weeks despite having a good appetite. She feels more sweaty than usual and has a fine tremor. Her heart rate is 110 beats/minute and her blood pressure is 100/70 mmHg.

Thyroid-stimulating hormone (TSH) 0.1 mU/L (0.5-5.7)

Free thyroxine (T4) 25 pmol/L (9-18)

Free triiodothyronine (T3) 28 pmol/L (3.5-6.5)

On examination, she has swelling on the right side of the anterior neck thought to be the right thyroid lobe. She was started immediately on propranolol. What is the SINGLE most appropriate management?

An 8 year old boy with a body mass index of 25 kg/m2 was admitted to a surgical ward following a road traffic accident. He was found to have glycosuria. When he recovered from his injury the glycasuria resolved. What is the SINGLE most appropriate follow-up investigation?

A 51 year old man was seen in the GP clinic for high blood pressure. He is currently taking ramipril, amlodipine and bendroflumethiazide for his blood pressure. His last recorded ambulatory blood pressure reading was 160/92 mmHg. He reports having headaches once or twice a week with palpitations and sweating. There is no evidence of papillary oedema and his abdominal examination is unremarkable. Blood test done a week ago reveals the following:

Haemoglobin 131 g/L (130-180)

White cell count 8 x 10^9 /L (4-11)

Platelets 350 x 10^9 /L (150-400)

Sodium 136 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5)

Creatinine 80 μmol/L (70-150)

eGFR >90 mL/min

Thyroid stimulating hormone 5.0 mU/L (0.5-5.7)

Which of the following is the SINGLE most appropriate investigation?

A 45 year old man presents with bitemporal hemianopia and swelling of his hands. He says that his nose has become larger and his voice has become more hoarse. On examination, spade-like hands are seen. What is the SINGLE most definitive test to confirm the diagnosis?

A 33 year old man comes to clinic to have an oral glucose tolerance test. What is the plasma glucose level two-hours after glucose intake which indicates an impaired glucose tolerance?

A 48 year old man presents with headaches and sweating. He has been having headaches for the past few months. He feels lethargic most of the day. He is known to have hypertension and is on enalapril, amlodipine, indapamide and doxazosin. His blood tests show that his insulin-like growth factor (IGF-1) is raised. His HbA1c is 47 mmol/mo (<48). What is the SINGLE most likely diagnosis?

A 26 year old man is admitted following a blood test in the community that reveals a sodium level of 115 mmol/L (135-145). He has been having more drowsiness and difficulty with concentration over the past few days. He was started with intravenous fluids in the hospital. His investigations done in the hospital show the following:

Haemoglobin 135 g/L (130-180)

White cell count 10 x 10^9 /L (4-11)

Platelets 360 x 10^9 /L (150-400)

Sodium 118 mmol/L (135-145)

Potassium 4.7 mmol/L (3.5-5)

Urea 6 mmol/L (20-7)

Creatinine 148 μmol/L (70-150)

eGFR >90 mL/min

Serum osmolality low

Urine asmolality high

What is the SINGLE most likely diagnosis?

A 41 year old obese woman has recently undergone a blood test. Her results show:

Fasting blood sugar 6 mmol/l

Oral glucose tolerance test 10.1 mmol/l.

What is the SINGLE most likely diagnosis?

A 56 year old man has noticed a strange tingling around his mouth for the past few weeks. It was very subtle at first but has become increasingly apparent. On examination, twitching facial muscles were noticed. His past medical history includes type 1 diabetes. What is the SINGLE most likely biochemical finding?

A 75 year old woman is admitted for a routine knee hemiarthroplasty. Post-operatively you are asked to review her as she has become less responsive. She has abdominal pain, and nausea and has vomited 3 times over the past hour. She has a history of Addison’s disease. A venous blood gas taken reveals:

Glucose of 3 mmol/L

Sodium 127 mmol/L (135-145)

Potassium 5.8 mmol/L (3.5-5)

Her blood pressure is 80/56 mmHg and she has a heart rate of 101 beats per minute. Lead II of her ECG is seen below:

What is the most appropriate immediate management?

A 23 year old male was found unconscious outside a local pub. The owner of the pub tried to rouse him but he remained semi-conscious and an ambulance was called. On arrival in Accident & Emergency, the paramedics tell you that the patient was sweating profusely, drowsy and mumbling incomprehensible words. There were also empty cans of beer strewn around the patient. An identification card found in the patient’s pocket reveals him to be a university student. Examination of the patient reveals a thin male. His skin appears diaphoretic and warm and his Glasgow coma scale (GCS) is 12/15. His observations are as follows:

A heart rate of 121 beats per minute

Blood pressure 88/55 mmHg

Temperature 37.2 °C

Oxygen saturation on room air 98%

What is the SINGLE most likely diagnosis for this patient?

A 43 year old woman has been having tremors and palpitations for several months. She describes swelling around both her eyes. She has lost 5 kg in the last 2 months. Clinical examination reveals periorbital oedema and eyelid lag. Which is the most likely diagnosis?

A 44 year old woman was referred to the endocrinology clinic following symptoms of increased thirst and increasing frequency of urination over the past few months. She started having symptoms of fatigue and constipation in the past few weeks. Her blood results from a week ago show the following:

Full blood count normal

eGFR 82 (>90)

Corrected calcium 2.95mmol/L (2.1-2.6 mmol/L)

Vitamin D 52 nmol/L (sufficient if >50 nnoml/L)

Parathyroid hormone 8.4 pmol/L (less than 0.8-8.5 pmol/L)

Phosphate 0.7mmol/L (0.8-1.4 mmol/L)

Her previous corrected calcium level a month ago was 2.82 mmol/L. What is the most likely diagnosis?