MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1564

A 50-year-old woman presents with agitation, high fever, sweating, and atrial fibrillation with a heart rate of 160 bpm after undergoing a CT pulmonary angiogram. She was recently discharged from the emergency department with a provisional diagnosis of pulmonary embolism and given an urgent CT pulmonary angiogram and treatment dose low molecular weight heparin two days ago. The patient has a medical history of breast cancer with liver metastases, depression, and COPD. She takes sertraline, letrozole, carbimazole, and as needed salbutamol. The patient’s shortness of breath has resolved, and the CT scan showed no evidence of pulmonary embolism and clear lung fields. On examination, the patient is very agitated, has tremors, is very hot to touch, and has ankle edema. Bilateral crepitations are heard on chest auscultation, and her temperature is 40.1ºC. Blood tests are pending. What is the most likely cause of her presentation?

MRCP2-1565

A 65-year-old male patient presents to the outpatient department with complaints of tiredness, lethargy, sweats, and weight loss over the past six months. He also reports diminished libido and erectile dysfunction. On examination, he appears pale with a resting pulse of 108 bpm and a bounding pulse. His blood pressure is 122/82 mmHg, and he has a smooth goitre. The GP has conducted several investigations, including haemoglobin, white cell count, platelets, sodium, potassium, urea, creatinine, alkaline phosphatase, calcium, TSH, free T4, and free T3. Which of the following is the most likely diagnosis?

MRCP2-1566

A 35-year-old man with chronic kidney disease due to polycystic kidney disease presents to his primary care physician with complaints of fatigue. He is currently taking lisinopril and hydrochlorothiazide for hypertension.

Upon examination, his blood pressure is 146/92 mmHg and he appears pale and fatigued. His pulse is regular at 78 bpm.

The following investigations were conducted:
– Hemoglobin: 110 g/L
– White blood cell count: 6.2 × 10^9/L
– Platelet count: 200 × 10^9/L
– Sodium: 140 mmol/L
– Potassium: 5.5 mmol/L
– Creatinine: 245 µmol/L
– Thyroid-stimulating hormone (TSH): 1.2 U/L (normal range: 0.5-4.5)
– Total T4: 50 nmol/L (normal range: 58-161)
– Free T4: 22 pmol/L (normal range: 9-27)
– Total T3: 0.9 nmol/L (normal range: 0.9-2.8)

What is the most likely diagnosis?

MRCP2-1567

A 56 year old Caucasian man with HIV presents with gradually worsening cough and shortness of breath over the last two years. He has a 50 pack year smoking history and has been told his blood pressure is high previously but had never previously been to see his GP about it to get it treated. His GP is unaware of his HIV diagnosis and his main point of healthcare contact is with the Genito-urinary medicine services.

However, for the last few days, he has been feeling faint and dizzy, especially when standing up. His breathlessness and cough are no worse than usual. He has no fever. On examination, his blood pressure is 91/76, his pulse is 94, and he is afebrile. His respiratory rate is 24, and his oxygen saturations are 92% on room air. He has a mild wheeze on auscultation of his chest. His heart sounds are faint, and his JVP is visible 3 cm above his sternal angle. There is no pitting edema. There is nothing else of note on examination.

An ECG on admission is normal.

Hb 14.0 g/dl
Platelets 199 * 109/l
WBC 6.2 * 109/l

Na+ 130 mmol/l
K+ 5.9 mmol/l
Urea 5.6 mmol/l
Creatinine 85 µmol/l
CRP 7 mg/l

What is the diagnosis?

MRCP2-1568

A 35-year-old woman who is 12 weeks pregnant presents with complaints of increasing fatigue, weight gain, feeling very cold, and severe constipation that only responds to high doses of laxatives. She has a history of well-controlled hypothyroidism on 50 micrograms of levothyroxine. On examination, she has thinning hair, slightly waxy skin, mild peripheral edema, and a larger body habitus than before. Her blood tests show calcium levels of 2.4 mmol/L (2.1-2.6), phosphate levels of 1.1 mmol/L (0.8-1.4), magnesium levels of 0.8 mmol/L (0.7-1.0), TSH levels of 5.0 mU/L (0.5-5.5), and free T4 levels of 9.8 pmol/L (9.0 – 18).

What is the most appropriate next step in management?

MRCP2-1569

A 32 year-old woman presents to her GP for her yearly check-up for her type 1 diabetes. She reports experiencing severe hypoglycaemic episodes during the night between 2-4am, which she noticed while working night shifts at a local supermarket. Her most recent HbA1c is 58 mmol/mol and her blood glucose levels often rise to around 15 mmol/mol by breakfast time. Currently, she is on a twice daily mixed insulin regimen. What would be the most appropriate modification to her current insulin treatment?

MRCP2-1570

A 62-year-old man with type 2 diabetes mellitus seeks advice on fasting during Ramadan. He is a devout Muslim and currently manages his diabetes with a combination of diet and metformin 500mg tds. His most recent HbA1c was 6.4% (46 mmol/mol). What is the best recommendation regarding his metformin if he decides to fast during Ramadan?

MRCP2-1555

A 48-year-old man presented to his GP after discovering high blood pressure readings at the local pharmacy. His blood pressure was measured at 180/100 mmHg in the surgery. The GP prescribed ramipril 2.5mg and titrated up to 10mg, but his blood pressure remained consistently high. Amlodipine was added, but had little effect even at the maximum dose. After a third agent failed to provide an adequate response, the GP referred the patient to the endocrine clinic.

During observation at the clinic, the man’s blood pressure was measured at 190/105 mmHg with a heart rate of 98 beats per minute. On examination, he was thin with a body mass index of 23 kg/m². His apex was diffuse and displaced with normal heart sounds. The chest was clear and abdomen was soft and non-tender with no evidence of masses or renal bruits. A hard, painless nodule was noted over his thyroid gland.

Further investigations revealed raised 24 hour urinary catecholamines and confirmed a diagnosis of phaeochromocytoma. The patient was treated with an alpha blocker and beta blocker while awaiting surgery. During this time, the thyroid nodule was also investigated and found to be a cold nodule on radionucleotide scanning.

What is the expected histological type of thyroid cancer in this case?

MRCP2-1571

A 49-year-old woman has presented to the endocrinology clinic for a follow-up on her hypothyroidism. She has been on a stable dose of 75 micrograms of levothyroxine, once daily, for the past 3 years but reports a recent decline in her symptoms over the last 8 weeks.

She complains of fatigue, low mood, constipation, and weight gain but confirms that she has not missed any doses of her medication.

She mentions that her GP has prescribed her a few new medications including citalopram, ferrous fumarate, ramipril, propranolol, and metformin, all of which she takes in the morning.

Today’s thyroid function tests show:

Thyroid-stimulating hormone (TSH) 12.4 mU/L (0.5-5.5)
Free thyroxine (T4) 3.6 pmol/L (9.0 – 18)

Her thyroid function tests from 3 months ago were:

Thyroid-stimulating hormone (TSH) 2.6 mU/L (0.5-5.5)
Free thyroxine (T4) 14.1 pmol/L (9.0 – 18)

Which of her medications could be responsible for her abnormal blood test results?

MRCP2-1556

A 35-year-old female presents to her physician with a complaint of a lump on the front of her neck. Upon examination, a 4 cm nodule is found on her thyroid gland that moves with swallowing.

The patient has a history of anxiety and depression and is currently taking sertaline 100mg once daily. Her mother was diagnosed with hypothyroidism in her 50s.

Thyroid function tests reveal the following results:

– Free T4: 14 pmol/L
– TSH: 2.6 mU/L

A fine needle aspiration confirms the presence of papillary thyroid cancer, but there is no evidence of metastasis. What is the most appropriate course of treatment?