MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1424

You are seeing a 55-year-old man with type 2 diabetes mellitus in the outpatient clinic. He has a past medical history of hypertension, mild left ventricular dysfunction and chronic kidney disease. He is currently on metformin and pioglitazone. Since last review he has gained 4kg in weight and his HbA1c has deteriorated to 68 mmol/mol from 60 mmol/mol. Body mass index today in clinic is 31 kg/m².

Recent blood tests are as follows:

Na+ 140 mmol/l
K+ 4.1 mmol/l
Urea 5 mmol/l
Creatinine 130 µmol/l

He was unable to previously tolerate exenatide due to injection site reactions. What would be the best alteration to his therapy?

MRCP2-1425

A 63-year-old man presents to the Emergency department with low impact fractures to two toes on his left foot. He has been taking canagliflozin for the past 6 months and has lost 5 kg in weight. His blood pressure has slightly decreased. On examination, his BP is 132/72 mmHg, pulse is 70/min and regular. His chest is clear, abdomen is soft and non-tender, and his BMI is 30. An x-ray confirms the fractures, and his creatinine is at the upper end of the normal range while his calcium level is 2.15 mmol/l (2.1-2.65). What is the most likely cause of the fractures?

MRCP2-1426

A 72-year-old male is admitted to the acute medical unit with a chest infection. His past medical history includes COPD and heart failure. His current medications include salbutamol, tiotropium, bisoprolol and ramipril. On examination you note right basal crepitations. The JVP is at 3 cm above the sternal angle. There is no peripheral oedema. His blood pressure is 150/90 mmHg.

You note that his blood results are as follows:

Na+ 122 mmol/l
Urine osmolarity 380 mosmol/l
Urine sodium 60 mosmol/l
Urea 5.8 mmol/l
Creatinine 60 µmol/l
fT3 5.8 pmol/l (normal range 3.5 – 7.8)
fT4 5.5 pmol/l (normal range 9.0 – 25.0)
TSH 0.1 mU/l (normal range 0.4 – 4.0)
morning cortisol normal

You water restrict the patient to 1.5 litres per day. On day 4 his bloods are reported as follows:

Na+ 120 mmol/l

What would be your plan of action for managing this patient?

MRCP2-1411

A 32-year-old woman has been referred to a specialist due to her hypertension not responding to combination therapy with ramipril, amlodipine, bendroflumethiazide, and atenolol. During her clinic visit, her blood pressure is measured at 181/105 mmHg. She reports urinating more than 10 times per day and some of her blood test results are provided below. What is the probable diagnosis?

MRCP2-1412

A 57-year-old woman presents with a 4 month history of abdominal pains, low mood and constipation. She has a past medical history of hypertension and depression following the death of her husband 3 years ago. During a routine visit to her GP, blood tests are performed and upon review, the patient is referred to the hospital.

The blood test results are as follows:

Hb 100 g/l
Platelets 230 * 109/l
WBC 10 * 109/l
Calcium (adjusted) 2.96 mmol/l
Phosphate 1.35 mmol/l
Na+ 135 mmol/l
K+ 4.7 mmol/l
Urea 6 mmol/l
Creatinine 110 µmol/l
CRP 30 mg/l
Albumin 35 g/L

What is the first diagnostic test that should be conducted?

MRCP2-1401

A 25-year-old female presents with worsening acne and a marked increase in the development of body and facial hair which she finds very distressing. She is also overweight and is markedly stressed by her physical appearance and the development of stretch marks over her abdomen. She has tried multiple hair removal techniques with only mild success.

On examination, she has a body mass index of 28 kg/m², coarse hair over the anterior and posterior part of her chest and under her chin. Her Blood Pressure is 135/90 mmHg.

Her lab results are as follows:

9:00 am Cortisol 345 nmol/l (170 700 nmol/l)
LH 17 iU/l (1 20 iU/l)
Basal FSH 7.1 iU/l (1.0 8.8 iU/l)
DHEAS 545 µg/dl (31 228 µg/dl)
Prolactin 160 mU/l (<360 mU/l)
17 OH Progesterone 1025 ng/dl (<80 ng/dl)
Testosterone 3.9 nmol/l (0.9 3.1 nmol/l)

Ultrasound abdomen and pelvis reveals two cysts in the right ovary.

What is the most appropriate treatment option for her condition?

MRCP2-1402

A 25-year-old nursing student presents to the Emergency Medical Unit after experiencing a third episode of collapse in the past six months while on clinical rotation. She has a history of mild eczema and irregular menstrual cycles, which are currently being investigated. Her grandfather and uncle have been diagnosed with type II diabetes mellitus.

On examination, her blood pressure is 110/70 mmHg, heart rate is 75 bpm and regular, and oxygen saturation is 96% on room air. All other physical exams are unremarkable. Laboratory results show elevated C peptide levels and a glucose level of 2.1 mmol/l.

Based on this information, what is the most likely cause of her recurrent collapses?

MRCP2-1403

A 25-year-old female presents with complaints of sleepiness, weakness, and vivid dreams that have been occurring for the past two months. She has a history of type 1 diabetes for six years and has been using basal bolus insulin for the last six months. She adheres to a good diet and regularly monitors her blood sugar levels. She lives with two other female student colleagues and binge drinks often on Saturday nights.

On examination, she appears well with a BMI of 23 kg/m2, a pulse of 80 bpm, and a blood pressure of 112/70 mmHg. No abnormalities are noted. Her investigations reveal a haemoglobin level of 152 g/L, white cell count of 6.8 ×109/L, platelets of 280 ×109/L, serum sodium of 146 mmol/L, serum potassium of 3.9 mmol/L, serum urea of 5.5 mmol/L, serum creatinine of 88 µmol/L, plasma glucose of 7.9 mmol/L, and HbA1c of 6.2%.

What is the most likely cause of her symptoms?

MRCP2-1404

A 64-year-old man of South-Asian ancestry presents to the Cancer Assessment Unit due to chest pain after receiving his first cycle of carboplatin, pemetrexed and pembrolizumab for his recently diagnosed advanced metastatic adenocarcinoma of the lung. He has a past medical history of hypercholesterolaemia, hypertension, atrial fibrillation and chronic kidney disease stage 3. Despite reporting no trouble with the chemotherapy, he has reproducible pain on palpation of the chest wall and is discharged home with simple analgesia. However, a nursing colleague alerts the team to an unreadable high capillary blood glucose. Blood tests reveal hyperglycaemia with a glucose level of 28 mmol/l. What is the most likely cause for this patient’s hyperglycaemia?

MRCP2-1405

A 49-year-old woman presents to the Emergency Department (ED) after collapsing at home. She reports experiencing chest tightness, palpitations, and dyspnoea over the past two years, which have lasted for minutes at a time. In the last few months, she has also developed non-specific pins and needles in her extremities and ‘spots before her eyes’. She smokes 20 cigarettes a day and drinks alcohol socially. Her GP started her on a tricyclic antidepressant two weeks ago for depression. Her mother died of a stroke at age 48. On examination, she is restless, has a pulse of 108 bpm and regular, and a blood pressure (BP) of 180/70 mmHg. She has a 2/6 pansystolic murmur loudest at the apex. Investigations reveal abnormal levels of haemoglobin, platelets, potassium, glucose, and corrected calcium. What is the most likely diagnosis?