A 50 year old man presents with hypertension, elevated blood sugars, terrible knee arthritis and severe daytime fatigue. His wife complaints of his loud snoring and he has a reduced libido. His shoe size has recently increased. He also says that he has a dull persistent headache for several weeks now.

An 18 year old female patient complains of ongoing heavy periods, fatigue and palpitations. Her GP has ordered a full blood exam. She asks you to interpret it.

 Patient Results |  Reference Range
Haemoglobin |  100.0 g/L |  (115-160)
Haematocrit |  0.318 |  (0.36-0.48)
Mean Cell Volume (MCV) |  79 fl |  80-100)
MCH |  31 pg |  (26.7-32.5)
MCHC|  27 g/dL |  (30.8-34.6)
Reticulocytes |  102 |  (50-100)
WBC |  4.9 |  (4.0-11.0)
Platelets |  180 |  (150-450)

Write a brief letter of referral to a GP including your clinical concerns and requests for specific investigations. 

A 24 year old female patient your opinion regarding how a person might get Chlamydia. She mentions her ex boyfriend had recently informed her by text message that he had had Chlamydia and that she should get tested. Ms X denies any symptoms and doesn't think she has got Chlamydia as she hasn't felt unwell and hasn't had any gynecological symptoms.

A 39-year-old woman presented with a painless swelling in her neck. The enlargement had been a gradual process over 2 years. She felt generally well.

Thyroid function tests:
T3 1.2nmol/l (NR 0.8-2.4)
T4 was 12nmol/l (NR 9-23)
TSH 6.3mU/l (NR 0.4-5mU/l).
AntiTPO 491 IU/ml (<35)
AntiTG 485 (<115)

Why does she present with relapsing/remitting Congestive heart failure at 35 years of age? Comment on the likely cause of the condition, & what should be done next.

A 37 yr old who is 20 weeks pregnant presents with L lion pain, nausea and aches and pains over the body. She denies any lower UTI symptoms.

Labs:

Thyroid function tests:
T3 4.8nmol/l (NR 0.8-2.4)
T4 48nmol/l (NR 9-23)
TSH 0.4mU/l (NR 0.4-5_mU/l).
Anti TSH antibodies were detected.

Mrs Grey is a 93 year old woman who sees you for treatment of her back pain. She states that she has been having some pain when urinating and she has lost her appetite. She has also noted 4 months of increasing fatigue, itchy skin and complains of having to get up several times to urinate at night. Her past history is of osteoarthritis & 50 years of hypertension

Sodium: 139 mmol/L ( 135 - 145 )
Potassium: 4.7 mmol/L ( 3.5 - 5.5 )
Chloride: 103 mmol/L ( 95 - 110 )
Bicarbonate: 29 mmol/L ( 20 - 32 )
Urea: 8.8 mmol/L ( 4.0 - 10.0 )
Creatinine: 85 umol/L ( 45 - 100 )
eGFR 53 (> 90)

PTH 85 (<65 pcg/mL)
Calcium 2.95 (2.13-2.65 mg/dL)
DEXA scan: T score < -2.5