MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine
MRCP2-1324
A 25-year-old patient with type 1 diabetes is brought to the Emergency Department by their family. They have been experiencing flu-like symptoms for a few days. During examination, their GCS is 10, and they have a respiratory rate of 35/min. Finger-prick blood glucose in the department is measured at 33.8 mmol/l and this is confirmed on venous sampling. Arterial blood gases reveal a pH of 7.02 and serum bicarbonate of 10 mmol/l. Electrolytes are abnormal, with potassium of 6.2 mmol/l, urea of 16.8 mmol/l and creatinine of 200 mmol/l. They weigh 70kg. What would be the most appropriate initial treatment for this patient?
MRCP2-1325
A 65-year-old man is admitted to the Emergency Department after being found collapsed and disoriented at home. He is unable to provide a clear medical history, and he has no family members to assist. Upon examination, his Glasgow Coma Scale (GCS) is 10/15, his pupils are reactive, and there are no neurological signs. He has a fever of 38.5°C, is dehydrated, and has a pulse rate of 125/min with a blood pressure of 110/60 mmHg, which drops by approximately 10 mmHg when he changes position. Upon auscultation of his chest, heart sounds 1 and 2 are audible with no murmurs. He is hypoxic with O2 sats of 89% on air and has dullness to percussion in his right lower zone with coarse breath sounds. His abdomen is soft with audible bowel sounds. Ophthalmoscopy reveals microaneurysms and exudates. The Emergency Department nurse dipsticks his urine, which shows +++ Glucose, and a finger blood glucose test indicates a reading greater than 40. Emergency blood gas results and other biochemistry tests reveal high levels of serum sodium, urea, creatinine, and amylase, as well as low levels of plasma glucose and HbA1c. Despite receiving enough 0.9% saline to match his initial fluid deficit, his sodium levels remain high. What is the appropriate choice of IV fluid treatment at this stage?
MRCP2-1326
A 57-year-old man with chronic kidney disease is coming in for an arthroscopy of the right knee. Upon admission to the Emergency Department, his potassium levels are at 5.9 mmol/l, creatinine at 450 μmol/l, and urea at 28 mmol/l. What is the most appropriate course of action for his surgery?
MRCP2-1327
A 22-year-old female presents to the Endocrine Clinic with concerns about excessive hair growth on her face and upper chest. She reports irregular periods since menarche at age 13. On examination, her BMI is 26 kg/m2 and her testosterone level is 3.5 nmol/l (normal range: 0.5-3.0 nmol/l) with an elevated LH/FSH ratio. What is the optimal long-term treatment plan for this patient?
MRCP2-1328
A 35-year-old woman with a 20-year history of type 1 diabetes presents to the clinic with complaints of frequent falls. She has fainted twice and hit her head, requiring emergency department visits, and experiences dizziness at other times. She has a history of peripheral neuropathy and sexual dysfunction. Her medication regimen includes insulin glargine and mealtime Novorapid™, as well as ramipril 5 mg/day for renoprotection and indapamide 2.5 mg. On examination, her blood pressure is 140/85 mmHg with a postural drop of 30 mmHg systolic. She exhibits signs consistent with peripheral sensory neuropathy to the mid-shin. Investigations:
Haemoglobin 130 g/l 135–175 g/l White cell count (WCC) 6.0 × 109/l 4–11 × 109/l Platelets 180 × 109/l 150–400 × 109/l Sodium (Na+) 138 mmol/l 135–145 mmol/l Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l Creatinine 110 µmol/l 50–120 µmol/l HbA1c 48 mmol/ml (6.51%) < 53 mmol/mol (<7.0%)
What is the most appropriate next step in management?
MRCP2-1329
A 40-year-old woman with a history of Graves’ disease, managed with a block replace regimen, presents to the clinic for a follow-up appointment after four months of treatment. She complains of a rash on both shins, which is not painful but unsightly. During the examination, mild proptosis consistent with Graves’ eye disease is observed, along with a raised, indurated, and discolored rash over both tibiae. Her vital signs are stable, with a blood pressure of 135/72 mmHg and a regular pulse of 78.
The following investigations are conducted: – Hb 137 g/L (115-160) – WCC 9.9 ×109/L (4-11) – PLT 203 ×109/L (150-400) – Na 138 mmol/L (135-146) – K 3.9 mmol/L (3.5-5.0) – Cr 100 µmol/L (79-118) – TSH 1.2 IU/L (0.5-4.5)
What would be the most appropriate way to manage her rash?
MRCP2-1330
An 80-year-old woman presents to a new General Practitioner (GP) for routine blood tests. The GP notices a raised corrected calcium level of 2.80 mmol/l and a raised parathyroid hormone (PTH) at 9 pmol/l. There is no history of renal stones, fractures or psychiatric disturbance. Other renal and liver function testing is unremarkable, full blood count is normal and there is no suspicion of underlying malignancy. Bone mineral density is at the lower end of the normal range. What is the most appropriate way to manage this patient?
MRCP2-1331
A 68-year-old man presents to the medical outpatient clinic with complaints of fatigue and tenderness in his neck. He was hospitalized six months ago for angina associated with atrial flutter, which resolved with intravenous digoxin. Currently, he is taking amiodarone 200 mg daily, aspirin 75 mg daily, atenolol 50 mg daily, and pravastatin 40 mg daily. His recent 24-hour ECG shows sinus rhythm with occasional ventricular ectopics. On examination, he has a fine tremor, a pulse of 56 beats per minute, and a blood pressure of 146/88 mmHg. Mild tenderness is noted in the thyroid area, but there is no obvious goitre. Laboratory investigations reveal a plasma free T4 level of 33.1 pmol/L (normal range: 10-22) and a plasma TSH level of <0.02 mU/L (normal range: 0.4-5). What is the optimal management plan for this patient?
MRCP2-1316
A 55-year-old man who drives a heavy goods vehicle presents to the diabetes clinic for evaluation. He is currently taking metformin 1g BD and gliclazide 160 mg BD for his diabetes. His blood sugar levels have been gradually increasing over the past few months and his latest HbA1c is 72 mmol/mol. He has gained 5kg in weight over the last 12 weeks, which he attributes to his work as a lorry driver. On examination, his blood pressure is 155/88 mmHg, pulse is regular at 75 beats per minute. His abdomen is soft and non-tender, and his body mass index is 37 kg/m².
An 80-year-old man with a history of localized squamous cell lung cancer presents to the Emergency Department with increasing confusion and peripheral muscle weakness. He reports feeling thirsty. Laboratory results show a hemoglobin level of 102 g/L, a white cell count of 12.1 x 10^9/L, and a platelet count of 167 x 10^9/L. His sodium level is 139 mmol/L, potassium level is 4.7 mmol/L, urea level is 6.2 mmol/L, creatinine level is 145 μmol/L, and calcium level is 3.2 mmol/L. His parathyroid hormone level is 1.9 pmol/L, which raises concern for pseudo hyperparathyroidism. After managing the acute hypercalcemia, what is the most appropriate long-term approach to treating the pseudo-hyperparathyroidism?