MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1414

A 30-year-old woman presents to the emergency department with 4 days of fevers and sweating. She has a past medical history of Graves’ disease and is not compliant with medication treatment. She smokes ten cigarettes daily and works in advertising.

Her vital signs are heart rate 146 beats per minute, blood pressure 154/99 mmHg, respiratory rate 24/minute, oxygen saturations 97% on room air and temperature 38.4ºC.

During examination, she is diaphoretic, tremulous and confused (Glasgow coma scale 14/15). Proptosis and chemosis are noted on examination of her eyes. There are bilateral crackles on chest auscultation and her JVP is elevated.

Blood tests reveal:

Hb 124 g/L Male: (135-180)
Female: (115 – 160)
Platelets 189 * 109/L (150 – 400)
WBC 5.3 * 109/L (4.0 – 11.0)
Na+ 131 mmol/L (135 – 145)
K+ 4.2 mmol/L (3.5 – 5.0)
Urea 5.4 mmol/L (2.0 – 7.0)
Creatinine 89 µmol/L (55 – 120)
CRP 4 mg/L (< 5)
Bilirubin 26 µmol/L (3 – 17)
ALP 122 u/L (30 – 100)
ALT 99 u/L (3 – 40)
γGT 74 u/L (8 – 60)
Albumin 34 g/L (35 – 50)
TSH 0.0 mIU/L (0.2 – 5.5)
Free T4 81 pmol/L (10 – 24.5)

What is the most appropriate treatment option for the likely diagnosis?

MRCP2-1415

A 68-year-old man visits his primary care physician complaining of increasing confusion and lethargy. He has a medical history of depression, Barrett’s esophagus, and benign prostatic hyperplasia. The patient is currently taking sertraline 100mg, lansoprazole 30 mg twice daily, and tamsulosin 400 mg. The following are the results of his blood tests:

– Hemoglobin: 104 g/l
– Platelets: 168* 109/l
– White blood cells: 8.7* 109/l
– Neutrophils: 2.5* 109/l
– Lymphocytes: 3.0* 109/l
– Eosinophils: 0.6 * 109/l
– Sodium: 118 mmol/l
– Potassium: 4.1 mmol/l
– Urea: 7.9mmol/l
– Creatinine: 173 µmol/l
– Corrected calcium: 3.01mmol/l
– Total protein: 95g/l
– Albumin: 30g/l

In addition, his urinary sodium is 7 mmol/l, urinary osmolality is 100 mOsm/kg, and plasma osmolality is 280 mOsm/kg. What is the most likely cause of this patient’s hyponatremia?

MRCP2-1416

A 67-year-old man presents to the clinic for a review of his medical history. He has a past medical history of hypercholesterolaemia, hypertension, depression, and an NSTEMI. On examination, he appears to be euvolaemic. His current medications include sertraline, bisoprolol, ramipril, and furosemide.

The patient’s blood results show a Hb of 138 g/l, platelets of 440 * 109/l, WBC of 10.8 * 109/l, glucose of 6.5 mmol/l, and creatinine of 86 µmol/l. His total cholesterol is 6.5 * 109/l, and his fasting triglycerides are 12.5 mmol/L (normal < 1.7). Additionally, a paired serum and urine osmolarity test was performed, with the serum osmolarity at 290 mOsmol/kg (normal 275-295) and the urine osmolarity at 600 mOsmol/kg. The urine sodium level was 40 mmol/l. What is the most likely cause of the hyponatraemia in this 67-year-old man?

MRCP2-1417

A 16-year-old male presents with short stature and a previous diagnosis of slipped femoral epiphysis at the age of 10. His younger brother has also recently been diagnosed with bilateral slipped femoral capital epiphysis at the age of 11. Family history is otherwise unremarkable and his development and progress at school are normal. On examination, he is on the 12th centile for height, has a BMI of 30, and normal pubertal development. Investigations reveal normal blood pressure, haemoglobin, white cell count, platelets, serum sodium, serum potassium, serum creatinine, and PTH levels, but low serum calcium and high serum phosphate levels. What is the most likely explanation for this boy’s presentation?

MRCP2-1418

A 55-year-old woman presents to an endocrinology clinic with a history of previously controlled Grave’s disease on carbimazole. She reports experiencing diarrhoea, palpitations, and heat intolerance for the past two months. The patient is Postmenopausal and has no relevant past medical history or recent illness. Thyroid function tests performed by her general practitioner show a TSH level of 0.2 (0.5-5.5 mu/L) and a Free T4 level of 25.2 (9-18 pmol/L). On examination, the patient is warm, tachycardic, and has a smooth, non-tender goitre, but no eye signs are noted.

What is the most appropriate treatment?

MRCP2-1419

A 50-year-old male complains of frequent sweating and persistent headaches.

An oral glucose tolerance test is conducted and the results are as follows:

Time (mins) 0 30 60 90 120
Growth hormone (ng/ml) 2.1 2.3 3.0 3.5 3.6
Glucose 9.5 11.2 12.1 13.5 16.1

What additional investigation will be necessary in the future, given the probable diagnosis?

MRCP2-1420

A 30-year-old female presents to the emergency department with severe right flank pain that radiates to her groin. She was recently referred to the rheumatology department by her GP for investigation of joint pains, dry eyes, and dry mouth. She is not taking any regular medication.

Upon examination, her blood pressure is 132/68 mmHg, and abdominal examination reveals right flank tenderness. The following blood test results were obtained:

– Na+ 136 mmol/L (135 – 145)
– K+ 2.8 mmol/L (3.5 – 5.0)
– Urea 3.6 mmol/L (2.0 – 7.0)
– Creatinine 70 µmol/L (55 – 120)
– Bicarbonate 9 mmol/L (22 – 28)
– Chloride 116 mmol/L (95 – 105)
– Calcium 2.3 mmol/L (2.1-2.6)
– Phosphate 1.1 mmol/L (0.8-1.4)

What is the most likely diagnosis?

MRCP2-1421

A 35-year-old south Asian woman presents to the emergency department with complaints of abdominal pain and suspected constipation. Upon examination, there is no edema and her blood pressure is 105/68 mmHg. The initial blood results and subsequent tests are as follows:

pH: 7.250
Bicarbonate: 18.0 mmol/l
Base excess: -8.0 mmol/l
Anion gap: Normal

Potassium: 7.2 mmol/l
Creatinine: 56 mmol/l
Glucose: 5.3 mmol/l
Thyroid function: Normal
Aldosterone: Normal
Renin: Normal
Protein electrophoresis & immunoglobulins: Normal
Urinary sodium: 94 mmol/l (normal range >20 mmol/L)
Urinary potassium: 26.8 mmol/l (normal range >25 mmol/L)
17- hydroxyprogesterone: Normal
Short synacthen test (basal): 320 nmol/l
Short synacthen test (30 mins): 750 nmol/l

What is the most likely diagnosis for this 35-year-old south Asian woman?

MRCP2-1422

A 63-year-old man presents to the clinic with complaints of increasing fatigue and lethargy over the past few months. He has a medical history of chronic renal failure, which he has been managing for the past five years, as well as type 1 diabetes.

During the examination, his blood pressure is 135/75 mmHg, and his pulse is regular at 70 beats per minute. The patient has pale conjunctivae and peripheral neuropathy with sensory loss in both feet.

Further investigations reveal a haemoglobin level of 117 g/L (135-177), a white cell count of 8.1 ×109/L (4-11), and platelets of 199 ×109/L (150-400). His sodium level is 138 mmol/L (135-146), potassium is 5.3 mmol/L (3.5-5), creatinine is 210 µmol/L (79-118), alkaline phosphatase is 165 U/L (39-117), calcium is 2.05 mmol/L (2.20-2.61), and PTH is 22 pmol/L (1.2-7.6).

What is the most likely underlying diagnosis for this patient?

MRCP2-1423

A 50-year-old male visited his doctor complaining of sweating, fatigue, and daytime tiredness that had been going on for 5 months. He believed his rings were tight due to ‘fluid retention’ and had been experiencing worsening headaches and vision problems.

The patient was diagnosed with acromegaly and underwent surgery for the condition a month ago. He has been feeling good since then and has not reported any new symptoms.

What would be the most effective test for monitoring the effectiveness of his treatment?