MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1662

A 42-year-old man comes to the endocrinology clinic for follow-up. He was diagnosed with Addison’s disease six months ago after experiencing symptoms of malaise, postural dizziness, and vomiting. He was started on hydrocortisone and has since reported improvement in his symptoms. His hydrocortisone dose was increased from 10mg in the morning and 5mg at lunchtime and 5mg in the early afternoon to 10mg, 10mg, and 5mg for the morning, lunchtime, and afternoon, respectively. However, he now presents with ankle swelling. On examination, he has non-pitting edema of his legs, a heart rate of 78 bpm, blood pressure of 165/102 mmHg, saturations of 98% on room air, and a respiratory rate of 14 breaths per minute. His previous blood pressure recorded in clinic had been 105/61 mmHg. He has no other medical problems and takes only paracetamol and ibuprofen as needed for headaches. What is the most appropriate course of action?

MRCP2-1663

A 50-year-old woman visits the clinic half a year after undergoing thyroid resection for differentiated thyroid cancer. She is in good health, has recuperated from her surgery, and has a well-healed scar on her neck. Her blood pressure is normal at 110/80 mmHg, and her pulse is regular at 60. Her body mass index remains at 25 kg/m², and she is only taking thyroid hormone replacement medication.

What is the best method to monitor for a potential recurrence?

MRCP2-1664

A 56-year-old woman was admitted due to abnormal blood tests during routine monitoring. She is currently receiving palliative chemotherapy for metastatic pancreatic cancer with FOLFIRINOX, which has caused her to experience vomiting, nausea, fatigue, and diarrhea. Her medical history includes hypothyroidism, epilepsy, and bipolar disorder, and she takes several medications regularly, including levothyroxine, levetiracetam, lithium, loperamide, paracetamol, oramorph, zomorph, movicol, and ondansetron.

Upon admission, her Na+ level was 142 mmol/l, K+ level was 3.8 mmol/l, urea level was 4.4mmol/l, creatinine level was 83µmol/l, and corrected calcium level was 3.3µmol/l. She was given IV 0.9% saline and 90 mg of IV alendronate after further blood tests were sent for and an ECG was performed. As part of her treatment plan, which of her regular medications should not be prescribed during her hospital stay?

MRCP2-1665

A 39-year-old man is under investigation for chronic metabolic acidosis with a suspected renal source. His anion gap is 9 mEq/L. What are the possible causes of renal tubular acidosis (type 2)?

MRCP2-1653

A 25-year-old woman visits a fertility clinic with her partner due to oligomenorrhoea and galactorrhoea. Despite 18 months of regular unprotected intercourse, she has been unable to conceive. Blood tests indicate a serum prolactin level of 6000 mIU/l (normal <500 mIU/l), and a pituitary MRI reveals a microprolactinoma. What is the most appropriate initial treatment?

MRCP2-1654

A 50-year-old man presents to the endocrinology clinic for evaluation of erectile dysfunction. He has been experiencing this problem for six months and has already consulted his GP. Low serum testosterone levels were found on initial and repeat testing, while LH and FSH levels were normal. The patient reports loss of nocturnal erections and decreased sexual desire, which has caused strain in his marriage. He also complains of worsening headaches at night and loss of energy. He attributes his stress at work to a recent promotion. What is the most likely cause of his erectile dysfunction?

MRCP2-1655

A 24-year-old man with type 1 diabetes presents at the emergency department complaining of abdominal pain and vomiting. He has been experiencing diarrhea for two days and became severely dehydrated, leading to vomiting. He has not taken his insulin for the past 24 hours. His usual insulin regimen includes Levemir as a long-acting insulin and Humalog as a short-acting insulin. He has no other medical conditions or regular medications. Upon admission, he is diagnosed with diabetic ketoacidosis due to acidosis, elevated serum ketones, and elevated blood glucose. He receives rapid fluid infusion. What type of insulin should be prescribed for him?

MRCP2-1656

A 78-year-old female comes to the clinic accompanied by her daughter, complaining of experiencing urinary incontinence for the past six months. She reports that she has never had any issues with continence before. Her medical history includes hypertension and angina. She now experiences urine leakage only when she laughs or coughs. Additionally, she has sudden urges to urinate throughout the day, resulting in leakage when she cannot reach the toilet in time. This has significantly affected her sleep, as it occurs more frequently at night. The patient has already reduced her caffeine intake and started bladder training as recommended by her GP. What other management strategies would you suggest?

MRCP2-1657

You are requested to assess a patient with hyperglycaemia on the ward. The patient is a 55-year-old male with type 1 diabetes mellitus. The nurse reports that his capillary blood glucose is 12.8 mmol/l. He is currently taking Humulin M3 (28 units before breakfast, and 38 units before evening meal) as per his drug history. He had his regular insulin with breakfast at 07:30.

You conduct a review at 11:30. The patient denies experiencing polyuria or polydipsia. He appears to be clinically euvolaemic. He is medically stable and is waiting for discharge from physiotherapy. You instruct the nurse to check plasma ketones, which come back at 0.4mmol/l. Upon examining his insulin chart, you observe that his blood glucose levels are typically well-managed.

What would be your approach to managing this patient?

MRCP2-1658

A 50-year-old woman is brought into the resuscitation room with a Glasgow coma scale of 11 (E2 V5 M4). A concerned family member called the emergency services, who found her in a moribund state. The family member states that she had seemed low over the past couple of months and that she had been wearing more layers of clothes than seemed appropriate.

On initial examination, she feels cool to touch. Pulse is regular and bradycardic with a heart rate of 38 beats per minute. Heart sounds 1+2 are present. Respiratory rate is 8 with oxygen saturations of 91% on 15 L. Auscultation of the chest is clear. Temperature is 33ºC. BM is 2.7.

Blood tests return as:

Hb 130 g/L Male: (135-180)
Female: (115 – 160)
Platelets 220 * 109/L (150 – 400)
WBC 9 * 109/L (4.0 – 11.0)

Calcium 2.5 mmol/L (2.1-2.6)
Thyroid stimulating hormone (TSH) 25 mU/L (0.5-5.5)
Free thyroxine (T4) 0.4 pmol/L (9.0 – 18)
Creatine kinase 6000 U/L (35 – 250)

Na+ 130 mmol/L (135 – 145)
K+ 4 mmol/L (3.5 – 5.0)
Bicarbonate 22 mmol/L (22 – 29)
Urea 8 mmol/L (2.0 – 7.0)
Creatinine 130 µmol/L (55 – 120)

What is the most appropriate management of this patient?