MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1508

A 22-year-old female presents to the emergency department with severe abdominal pain, vomiting, and lethargy. She reports feeling generally unwell for the past six months, during which time she has lost 12 kg in weight and has been constantly fatigued. Her mother and sister have hypothyroidism and take thyroxine. One month ago, she was diagnosed with hypothyroidism and started on levothyroxine 50 mcg daily. On examination, she appears unwell and dehydrated, with a pulse of 105 beats per minute and blood pressure of 70/40 mmHg. Her temperature is 37.6ºC and BMI is 19 kg/m². Cardiovascular, respiratory, and abdominal examinations are unremarkable. Previous investigations showed Hb 9.5 g/dl, MCV 105 fl, platelets 190 * 109/l, WBC 4.5 * 109/l, serum free T4 8.5 pmol/l, and serum TSH 5.5 mU/l. While awaiting new investigations, what is the most appropriate immediate treatment for this patient?

MRCP2-1501

A 25-year-old man with a history of Von Hippel Lindau syndrome presents to his GP for a routine mood review. He has previously been well but has retinal haemangiomas. He is currently taking venlafaxine for improved mood following a recent relationship break down. Despite using mindfulness to control panic attacks, he still experiences palpitations and clamminess.

During the examination, the patient appears alert and in good health. However, his blood pressure is measured at 170/110 mmHg. Fundoscopy reveals no haemorrhages or cotton wool spots, and his visual acuity is 6/6 bilaterally. There are no palpable masses in his abdomen.

The patient’s blood test results show normal levels of Na+, K+, HCO3, urea, and creatinine, but his TSH level is 3.2 mU/l (range 0-4). An ECG reveals large QRS complexes consistent with left ventricular hypertrophy.

What is the most likely explanation for the patient’s symptoms?

MRCP2-1502

A 25-year-old woman presents to the Emergency department following a collapse at the local supermarket. She reports feeling weak and fatigued most of the time and rarely seeks medical attention. She has no regular medication. On examination, her blood pressure is 100/70 mmHg, pulse is 80 beats per minute and regular. She has a BMI of 21 kg/m² and no abnormal physical signs are noted.

Investigations

Na+ 140 mmol/l
K+ 3.1 mmol/l
HCO3- 32 mmol/l
Urea 5.9 mmol/l
Creatinine 85 µmol/l

What is the most likely diagnosis?

MRCP2-1503

A 24-year-old woman with a history of polycystic kidney disease and chronic kidney disease presents to the Endocrinology Clinic for her annual review. She reports experiencing intermittent abdominal pain and generalised aches over the past two weeks, as well as feeling thirsty. She is currently on the waiting list for a kidney transplant. Her routine blood tests reveal several abnormalities, including a low haemoglobin level, high white cell count and platelet count, elevated urea and creatinine levels, and a high calcium level. What condition has this patient developed that could explain the abnormal calcium level?

MRCP2-1504

A 63-year-old male, who recently immigrated from India, presents with a 5-day history of feeling generally unwell. His niece, who is with him at the hospital, denies any recent productive cough, diarrhea, vomiting, or dysuria. The patient has been gradually becoming more malaised over the past 5 days and has not been eating or drinking well. He has no known medical history. On examination, he has dry mucous membranes and cool peripheries, and his JVP is +1 cm above the angle of Louis. Heart sounds, chest, and abdomen are unremarkable. Urine dip and chest radiograph results are pending. The patient’s blood tests reveal:

– WBC: 16 * 109/l
– Neutrophils: 14.8 * 109/l
– Na+: 152 mmol/l
– K+: 3.7 mmol/l
– Urea: 22 mmol/l
– Creatinine: 208 µmol/l
– CRP: 38 mg/l
– Glucose: 38 mmol/l
– Ketones: 2.8 mmol/l

Arterial blood gases:

– pH: 7.31
– PaO2: 20.2 kPa
– PaCO2: 3.0 kPa
– Bicarbonate: 16 mmol/l
– Lactate: 4 mmol/l

What is the likely diagnosis that unifies these symptoms and test results?

MRCP2-1493

A 35-year-old female presents to the emergency department as a stand-by due to feeling unwell for the past 2 weeks. She reports experiencing lethargy, occasional shortness of breath, and light-headedness. Recently, she has also been experiencing urinary frequency and dysuria. Her general practitioner visited her at home 2 days ago and prescribed trimethoprim for a possible urinary tract infection.

Upon arrival, the patient appears pale and clammy, with cold peripheries. Her vital signs reveal oxygen saturations of 94% on air, a respiratory rate of 28/min, a heart rate of 117/min, and a blood pressure of 65/30 mmHg.

The patient has a medical history of type 1 diabetes, hypothyroidism, and uterine fibroids.

Initial investigations show:

– White cell count: 17.8 *109/l
– Haemoglobin: 97 g/l
– Mean cell volume (MCV): 103.7 fL
– Sodium: 134 mmol/l
– Potassium: 4.9 mmol/l
– Urea: 7.0 mmol/l
– Creatinine: 120 µmol/l
– Bilirubin: 45 µmol/l
– Alanine transaminase (ALT): 1051 U/l
– Albumin: 16 g/l
– C-reactive protein (CRP): 71 mg/dL
– Glucose: 9.1 mmol/l

Urinalysis shows: ++protein, ++blood, +++leukocytes, ++nitrites, trace ketones.

The patient is given intravenous fluids, and her blood pressure increases to 82/45 mmHg after receiving a total of 3 litres of fluids. She is started on intravenous amoxicillin and gentamicin.

What is the next step in managing this patient?

MRCP2-1494

A 65-year-old woman with a history of type 2 diabetes presents for a check-up. She has a mild cardiac failure that is being managed with ramipril and bisoprolol. Her current medication for diabetes is metformin 1g BD. During examination, her blood pressure is 122/82 mmHg, pulse is regular at 80 beats per minute. Bilateral basal crackles are heard on auscultation of the chest, and there is pitting oedema of both ankles. Her body mass index is elevated at 33 kg/m².

HbA1c 73 mmol/mol
Creatinine 82 µmol/l

What is the most appropriate next step for managing glucose control?

MRCP2-1495

A 25-year-old woman with limited exposure to medical services presents to the Endocrinology Clinic. She has never had a period and previously felt this was due to having a short height, but she has recently decided to seek advice.
On examination, she is significantly shorter than would be expected, given her parental height; her nipples are widely spaced and there is a suspicion of a high-arched palate. There appears to be a failure of secondary sexual characteristics. Her blood pressure is elevated at 149/90 mmHg.
Investigations reveal a follicle-stimulating hormone (FSH) level of > 40 IU/l on at least two occasions.
Given the likely diagnosis, what is the most likely complication in this patient?

MRCP2-1496

A 14-year-old boy presents with several months of muscle cramps and weakness all over his body. He also reports having an increased thirst and a strong desire for salty foods. He has no significant medical history.

During the examination, the boy appears to be in good health. His vital signs are as follows:
Respiratory rate of 18/min
Blood pressure of 116/78 mmHg
Heart rate of 78/min

Blood tests are performed, and the results are as follows:

Na+ 129 mmol/L (135 – 145)
K+ 2.8 mmol/L (3.5 – 5.0)
Magnesium 0.54 mmol/L (0.7 – 1.0)

A urine dipstick test shows no glucose or protein present. A urine sample is sent to the lab for further analysis:

Urine calcium/creatinine ratio 0.05 (<0.14) What is the most probable diagnosis?

MRCP2-1497

A 55-year-old obese HGV driver, who takes BD Novomix 30 insulin, visits your outpatient clinic seeking clarification on driving regulations he overheard while dining with colleagues. He is extremely anxious and tearful, fearing that his diabetes may cost him his livelihood.

The patient was diagnosed with type 2 diabetes 9 years ago and became insulin dependent 2 years ago. He reports good compliance with insulin every day. However, 18 months ago, he experienced dizziness after exercising and taking the same units of insulin. A spot blood glucose check revealed a reading of 2.8 mmol/l, which improved immediately after drinking Lucozade that he carried with him. He has no other medical history and no visual field or peripheral nerve impairments.

What advice would you give him regarding driving?