MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1311

A 25-year-old male has been referred by his doctor due to concerns about his sexual health. He has recently started a sexual relationship but is having difficulty achieving an erection and is worried about his poor sexual development. He reports that his pubertal development was also poor, with little pubic hair and embarrassment about his gonadal development. He works as a laborer on a building site, is physically active, and has no formal qualifications. He drinks 20 units of alcohol per week, mostly on weekends, and has one younger brother.

During examination, the patient appears phenotypically normal but is tall and lean with a BMI of 21.2 kg/m2. He has little beard growth, fine skin, and scanty body and pubic hair. His penile length is approximately 6 cm, and his testicular volumes are approximately 6-7 ml bilaterally (normal 10-15 ml). Cardiovascular, respiratory, and abdominal examination are all normal, and fundal examination and visual fields are normal as well.

Further investigations reveal a plasma testosterone concentration of 6.2 nmol/L (normal range 10-30), LH of 20.2 mU/L (normal range 2-10), FSH of 22.2 mU/L (normal range 2-10), prolactin of 433 mU/L (normal range 50-500), free T4 of 12.6 pmol/L (normal range 10-22), and TSH of 2.3 mU/L (normal range 0.4-5).

What is the likelihood of his brother developing this condition?

MRCP2-1312

A 45-year-old accountant presented to the medical assessment unit with a 2-month history of polyuria and elevated blood glucose levels. There was no family history of diabetes and she was not currently on any medication. On examination, her body mass index was 23 kg/m2 with normal general physical and systemic examination. Urine was negative for ketones.

Blood glucose 16.5 mmol/l
pH 7.40
HCO3 25 mmol/l
Na+ 140 mmol/l
K+ 3.7 mmol/l

What test may be useful in establishing the underlying diagnosis considering her clinical profile?

MRCP2-1313

A 70-year-old male was admitted with worsening shortness of breath and fever that had been getting worse over the past three days. He had been in good health prior to this, but had recently returned from a trip to Italy with his wife. He has a history of type 2 diabetes, which has been managed with diet alone for the past three years. He is also a smoker, consuming five cigarettes per day.

During the examination, the patient appeared slightly confused and had a tan. His oxygen saturation was 92% on room air. He had a fever of 40°C, a heart rate of 118 bpm, and a blood pressure of 118/90 mmHg. Crackles were heard in the left lower lung field upon auscultation.

The following investigations were conducted:
– Hemoglobin: 143 g/L (normal range: 115-165)
– White blood cell count: 8.2 ×109/L (normal range: 4-11)
– Platelets: 320 ×109/L (normal range: 150-400)
– Serum sodium: 128 mmol/L (normal range: 137-144)
– Serum potassium: 3.6 mmol/L (normal range: 3.5-4.9)
– Serum urea: 8.2 mmol/L (normal range: 2.5-7.5)
– Serum glucose: 10.9 mmol/L (normal range: 3.0-6.0)
– Urine sodium: 15 mmol/L
– Arterial blood gases:
– pH: 7.36 (normal range: 7.36-7.44)
– pCO2: 5.1 kPa (normal range: 4.7-6.0)
– pO2: 10.7 kPa (normal range: 11.3-12.6)
– Standard HCO3: 30 mmol/L (normal range: 20-28)

What is the appropriate treatment for this patient’s hyponatremia?

MRCP2-1314

A 70-year-old male was admitted with worsening shortness of breath and fever that had been deteriorating over the past three days. He had been in good health prior to this and had recently returned from a trip to Italy with his wife. He has a history of hypertension and is a former smoker, having quit 10 years ago.

On examination, he appeared flushed and confused with oxygen saturation of 90% on room air. He had a temperature of 39°C, a heart rate of 110 bpm, and a blood pressure of 130/80 mmHg. Crackles were heard in the right lower lung field.

Laboratory investigations revealed:
– Hemoglobin: 140 g/L (130-170)
– White blood cell count: 9.5 × 109/L (4-11)
– Platelets: 280 × 109/L (150-400)
– Serum sodium: 130 mmol/L (135-145)
– Serum potassium: 4.0 mmol/L (3.5-5.0)
– Urea: 6.0 mmol/L (2.5-7.5)
– Plasma glucose: 8.5 mmol/L (3.0-6.0)
– Urine sodium concentration: 40 mmol/L
– Arterial blood gas analysis:
– pH: 7.38 (7.35-7.45)
– pCO2: 5.0 kPa / 38 mmHg (4.7-6.0 kPa)
– pO2: 9.5 kPa / 71 mmHg (11.3-12.6 kPa)
– Standard bicarbonate: 30 mmol/L (22-28)

Which diagnostic test would be most helpful in determining the cause of the patient’s symptoms?

MRCP2-1315

A 43-year-old woman presents to your clinic. During a recent blood test ordered by her GP, it was noted that her TSH was < 0.1 mU/l. She has a history of thyroid cancer that has been surgically removed and is currently taking 100mcg of levothyroxine daily. She reports no other medical issues or symptoms. What is the recommended course of action?

MRCP2-1287

A 70-year-old Japanese male presents to the emergency department with sudden onset shortness of breath associated with palpitations. He has previously experienced similar palpitations 8 months ago but did not seek medical attention. He was last completely well and described by his son to be at baseline 24 hours ago when they had lunch together. The patient denies any chest pain, nausea, vomiting or sweating. On examination, the patient is pyrexic at 38.5 degrees and tachycardic, with a regular pulse at 130-140 beats per minute. Heart sounds demonstrate a gallop rhythm; auscultation of his chest reveals bibasal inspiratory coarse crackles and no wheeze. He has bilateral mild lower limb pitting oedema to low ankles. Examination of the abdominal and neurological systems is unremarkable. A chest radiograph demonstrates bibasal alveolar shadowing with mild bilateral pleural effusions. An ECG demonstrated sinus tachycardia at 130 beats per minute. Blood tests are as follows:

Hb 120 g/l
Platelets 280 * 109/l
WBC 8.5 * 109/l

Na+ 140 mmol/l
K+ 4.0 mmol/l
Urea 6.8 mmol/l
Creatinine 95 µmol/l

TSH < 0.01 mU/l
Free T4 135 pmol/l
Free T3 38 pmol/l

Nursing staff have kindly taken blood cultures and taken measures to cool the patient. What is the next most appropriate immediate treatment?

MRCP2-1288

A 67-year-old woman presents to the endocrinology department with complaints of enlarging hands and feet, difficulty wearing her usual rings, and changes in her facial appearance. She also reports persistent sweating and joint pain.

On examination, she has coarsened facial features, macroglossia, and spade-like hands and feet. Neurological examination reveals bitemporal hemianopia. Blood tests show elevated IGF-1 levels and failure to suppress growth hormone with an oral glucose load. An MRI reveals a large pituitary macroadenoma, which is partially removed through trans-sphenoidal surgery. However, the patient continues to experience sweating, arthralgia, and fatigue, and a repeat MRI shows residual tumor that is inaccessible to further surgical intervention.

Given the likely diagnosis, what is the most appropriate management at this point?

MRCP2-1289

You receive a call from a general practitioner regarding a 55-year-old man who has undergone thyroid function tests due to a history of weight loss. The results show TSH 0.01 mIU/L and T4 8.5 ug/dL, with no history of illicitly taking levothyroxine. Which of the following advice should you give?

MRCP2-1290

A 50-year-old woman presents to the hospital with abdominal pain and malaise. She has no medical history and does not take any regular medications or supplements. Upon blood tests, her calcium level is 2.70 mmol/l, phosphate level is 1.2 mmol/l, and creatinine level is 60 µmol/l. A chest X-ray shows normal appearances. The patient denies taking any medications or supplements, and her renal function is normal. Upon contacting the GP, it is discovered that her calcium was slightly elevated 10 years ago. Based on these findings, what is the most likely diagnosis?

MRCP2-1291

A 70-year-old male presents with confusion and drowsiness. His family reports a 5-day history of productive cough and shortness of breath. He has a medical history of type 2 diabetes mellitus, hypertension, and hypercholesterolemia. His regular medications include metformin 500 mg thrice daily, gliclazide 80 mg twice daily, amlodipine 5 mg daily, and simvastatin 40 mg nightly. Upon examination, he appears confused with dry mucous membranes, a blood pressure of 100/50 mmHg, a pulse of 110/min, a temperature of 37.6 oC, and a respiratory rate of 20/min. Crackles are heard at the right base, and his pulse is weak with a capillary refill of 3 seconds. Jugular venous pressure is not visible. Capillary blood glucose is found to be HI.

A venous blood sample is collected, revealing the following results:

Hb 129 g/l Na+ 161 mmol/l
Platelets 204 * 109/l K+ 4.9 mmol/l
WBC 13.1 * 109/l Urea 15.2 mmol/l
Neuts 11.9 * 109/l Creatinine 97 µmol/l
Glucose 56 mmol/l eGFR 62 mg/l
Ketones 1.9 mmol/l HbA1c 75 mmol/mol
pH 7.35 HCO3 20 mmol/mol

What would be your first course of treatment?