A 48-year-old man presented with an infected ulcer, measuring 2 ? 1 cm, over the right first metatarsal head, with surrounding cellulitis. He had no previous history of diabetes mellitus but had been told by his general practitioner some years previously that his blood glucose was 'borderline'.
On examination, his temperature was 37.4C, his blood pressure was 158/92 mmHg and his body mass index was 31.5 kg/m2 (18-25). His foot pulses were easily palpable but he had a sensory neuropathy.
Investigations:
random plasma glucose16.4 mmol/L
haemoglobin A1c81 mmol/mol (20-42)
What is the most appropriate treatment for his hyperglycaemia?

• A. gliclazide 40 mg twice daily
• B. exenatide 5 micrograms twice daily
• C. metformin 500 mg twice daily
• D. soluble insulin before meals, basal insulin at bedtime
• E. sitagliptin 100 mg once daily

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

• A. X-linked recessive
• B. autosomal dominant
• C. autosomal recessive
• D. X-linked dominant
• E. mitochondrial

A 43-year-old woman was admitted with right lower lobe pneumonia and was found to have atrial fibrillation. She had a history of bipolar disorder for which she was taking lithium. Her menstrual periods were normal.
Investigations on admission:
serum thyroid-stimulating hormone (TSH)0.98 mU/L (0.4-5.0)
serum free T428.1 pmol/L (10.0-22.0)
serum free T314.2 pmol/L (3.0-7.0)
Assay interference had been excluded.
Subsequent investigations:
serum sex hormone binding globulin64 nmol/L (40-137)
serum thyroid-hormone receptor ?-subunit0.8 IU/L (<1.0)
anti-thyroid peroxidase antibodiesnegative
What is the most likely diagnosis?

• A. surreptitious ingestion of thyroxine
• B. lithium-induced hyperthyroidism
• C. thyroid hormone resistance
• D. TSHoma
• E. non-thyroidal illness (sick euthyroid syndrome)

A 72-year-old woman presented with a painless swelling in the front of the neck, which she had first noticed 2-3 months previously. She was otherwise well, with no symptoms of mass effect in her neck, and was not taking any medication.
On examination, her thyroid gland was moderately enlarged, and felt uniformly nodular. There was no associated lymphadenopathy. Her pulse was 78 beats per minute and regular, and there were no signs of thyrotoxicosis.
Investigations:
serum thyroid-stimulating hormone<0.01 mU/L (0.4-5.0)
serum free T424.8 pmol/L (10.0-22.0)
serum free T310.3 pmol/L (3.0-7.0)
technetium-99m scan of thyroid (20-min uptake)patchy uptake in both thyroid lobes
What is the most appropriate management?

• A. carbimazole plus levothyroxine
• B. total thyroidectomy
• C. repeat thyroid function tests after 6 months
• D. partial thyroidectomy
• E. radioiodine

A 32-year-old woman with a recurrent history of Graves' thyrotoxicosis was being considered for radioiodine treatment. However, she wanted to conceive again at some stage and asked how soon she could become pregnant.
After what minimum interval would it be safe for her to conceive again?

• A. 4 months
• B. 8 months
• C. 6 months
• D. 12 months
• E. 2 months