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NO.1 A 75-year-old woman presented with a 4-week history of lethargy. Her medical history was
unremarkable and she took no medication.
On examination, her blood pressure was 140/70 mmHg lying. She was euvolaemic.
Investigations:
serum sodium120 mmol/L (137-144)
serum potassium3.8 mmol/L (3.5-4.9)
serum urea3.0 mmol/L (2.5-7.0)
serum creatinine75 umol/L (60-110)
short tetracosactide (Synacthen@) test (250 micrograms):
baseline serum cortisol450 nmol/L (200-700)
serum cortisol (30 min after tetracosactide)600 nmol/L (>550)
serum thyroid-stimulating hormone2.5 mU/L (0.4-5.0)
serum free T416.9 pmol/L (10.0-22.0)
urinary sodium70 mmol/L
What is the most appropriate initial management?
A. tolvaptan
B. intravenous sodium chloride 0.9%
C. fluid restriction
D. hydrocortisone
E. demeclocycline
Answer: C

NO.2 A 72-year-old woman was referred for bone density assessment after sustaining a fracture of
her right ankle after a minor fall. She had previously fractured her right wrist after tripping in the
street. Her past medical history included occasional angina relieved by glyceryl trinitrate spray and a
previous deep venous thrombosis. Her medication comprised aspirin, simvastatin, alendronic acid,
and calcium and vitamin D, which she had been taking regularly for 2 years.
Investigations:
DXA scan of spine (L2-L4)T score -2.4
DXA scan of total hipT score -2.8
What is the most appropriate treatment?
A. switch alendronic acid to pamidronate
B. continue alendronic acid
C. switch alendronic acid to strontium ranelate
D. switch alendronic acid to teriparatide
E. switch alendronic acid to raloxifene
Answer: B

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