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A 40-year-old man presented with a 4-month history of increasing central obesity. His medical history included HIV infection and allergic rhinitis. He was taking highly active antiretroviral therapy and nasal fluticasone.
On examination, he had marked central adiposity. His blood pressure was 160/95 mmHg.
Investigations:
serum sodium140 mmol/L (137-144)
serum potassium3.8 mmol/L (3.5-4.9)
serum cholesterol5.5 mmol/L (<5.2)
fasting serum triglycerides8.20 mmol/L (0.45-1.69)
serum cortisol (09.00 h)<50 nmol/L (200-700)
serum thyroid-stimulating hormone4.6 mU/L (0.4-5.0)
serum free T49.3 pmol/L (10.0-22.0)
What is the most likely diagnosis?

• A. Cushing's syndrome
• B. glucocorticoid resistance
• C. Addison's disease
• D. HIV-associated lipodystrophy
• E. hypothyroidism

A 26-year-old man presented urgently, complaining of muscle pains. He had been found to have heterozygous familial hypercholesterolaemia 2 years previously owing to a mutation in the PCSK9 gene. He had a strong family history of premature vascular disease. He was taking atorvastatin 80 mg daily.
Investigations:
serum creatine kinase2782 U/L (24-195)
serum cholesterol5.7 mmol/L (<5.2)
After stopping atorvastatin, his serum creatine kinase fell to within the normal range.
What is the most appropriate next step in management?

• A. start fenofibrate 100 mg
• B. restart atorvastatin 40 mg
• C. start ezetimibe 10 mg
• D. restart atorvastatin 10 mg
• E. start fluvastatin 40 mg

An 18-year-old man, whose ambition was to become a member of the elite armed forces, presented with gynaecomastia. His weekly alcohol consumption was 35 units.
On examination, he had normal secondary sexual characteristics, a well-developed, muscular physique and modest, slightly tender bilateral gynaecomastia. Testes were 10 mL with soft texture.
Investigations:
haemoglobin160 g/L (130-180)
MCV96 fL (80-96)
serum dehydroepiandrosterone sulphate4 umol/L (2-10)
serum oestradiol180 pmol/L (<180)
serum testosterone (09.00 h)6.0 nmol/L (9.0-35.0)
plasma follicle-stimulating hormone1.0 U/L (1.0-7.0)
plasma luteinising hormone0.7 U/L (1.0-10.0)
serum prolactin420 mU/L (<360)
What is the most likely diagnosis?

• A. androgen abuse
• B. primary hypogonadotrophic hypogonadism
• C. oestrogen-secreting testicular tumour
• D. persistence of pubertal gynaecomastia
• E. alcohol excess

A 32-year-old man presented to the fertility clinic with his partner. The couple had been together for 4 years and had been trying to conceive for the past 3 years. His partner had children from a previous marriage.
On examination, he was healthy, thin and tall but had bilateral gynaecomastia. His testes felt firm and testicular volumes were 5-6 mL. He had normal pubic and axillary hair.
Investigations:
serum testosterone10.0 nmol/L (9.0-35.0) plasma follicle-stimulating hormone45.0 U/L (1.0-7.0) plasma luteinising hormone32.0 U/L (1.0-10.0)
chromosomal studiesmosaic pattern of 47 XXY/46 XY
semen analysisazoospermia testicular biopsyno viable spermatozoa
What intervention is most likely to lead to conception?

• A. human chorionic gonadotropin
• B. pulsatile gonadotropin-releasing hormone
• C. intracytoplasmic sperm injection
• D. artificial insemination by donor
• E. testosterone

A 34-year-old woman presented with palpitations, heat intolerance and a slight tremor. She was 9 weeks into her first pregnancy. She had not had any morning sickness.
On examination, her pulse was 100 beats per minute. She had a small uniform goitre but no tremor and no eye signs.
Investigations:
serum thyroid-stimulating hormone<0.01 mU/L (0.4-5.0)
serum free T442.0 pmol/L (10.0-22.0)
serum free T315.0 pmol/L (3.0-7.0)
anti-thyroid-stimulating hormone receptor
antibodies14 U/L (<7)
The decision was taken to treat her Graves' disease with propylthiouracil (PTU) rather than carbimazole.
What is the reason for this decision?

• A. concordance with PTU is greater
• B. PTU is less associated with agranulocytosis
• C. PTU is less associated with aplasia cutis
• D. PTU is less associated with hepatitis
• E. PTU does not cross the placenta