MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1279

A 50-year-old male presents with difficulty sleeping, weight loss, and anxiety. He has been taking combined cyclical oestrogen/progesterone hormone replacement therapy for the past two years. On examination, he has a body mass index of 25 kg/m2, a pulse of 100 beats per minute, and a blood pressure of 118/76 mmHg. No goitre is palpable, and eye movements are normal. Weakness of the proximal musculature of the shoulder and hip girdles is noted. Abdominal examination reveals a palpable splenic tip.

Initial investigations reveal the following:
– Serum total thyroxine 260 nmol/L (60-140)
– Plasma TSH <0.1 mU/L (0.4-5.0)
– Serum alkaline phosphatase 190 U/L (45-105)
– Serum gamma glutamyl transferase 28 U/L (4-35)

The patient’s GP prescribes carbimazole 10 mg tds and propranolol 120 mg BD. At the six-week review, the patient appears clinically euthyroid. Repeat investigations show:
– Free thyroxine 190 nmol/L
– Plasma TSH 2.5 mU/L
– Serum alkaline phosphatase 170 U/L
– Serum gamma glutamyl transferase 35 U/L

The dose of carbimazole is decreased to 20 mg daily. After one year, the GP decides to refer the patient to endocrine outpatients. Two weeks before the appointment, the patient had a chest infection treated with erythromycin. His blood test results show:
– Serum thyroxine 85 nmol/L
– Plasma TSH 11.2 mU/L
– Serum alkaline phosphatase 100 U/L

What would be the most appropriate next investigation?

MRCP2-1280

A 62-year-old man presents to the clinic for a review of his medical condition. He has a past medical history of ischemic heart disease and was diagnosed with type 2 diabetes mellitus about a year ago. His HbA1c at the time of diagnosis was 7.6% (60 mmol/mol), and he was started on metformin, which was gradually increased to a dose of 1g bd. His most recent blood test shows an HbA1c of 6.8% (51 mmol/mol). He has recently retired from his job in the IT industry, and his current BMI is 28 kg/m². He is taking the following medications:

– Atorvastatin 80 mg once daily
– Aspirin 75 mg once daily
– Bisoprolol 2.5 mg once daily
– Ramipril 5mg once daily

What would be the most appropriate next step for this patient?

MRCP2-1281

A 49-year-old woman presents to the surgical ward with severe abdominal pain radiating from her loin to groin. A CT-KUB scan reveals the presence of a renal calculus on the right side. During the admission process, she confides in you that she has been feeling unwell for the past few weeks, experiencing symptoms such as altered mood, constipation, polyuria, and polydipsia.

Upon conducting blood tests, the following results were obtained:

– Estimated glomerular filtration rate >60 ml/min
– Adjusted calcium 3.1 mmol/l (2.1-2.6 mmol/l)
– Phosphate 0.6 mmol/l (0.8-1.4 mol/l)
– Parathyroid hormone 5.1 pmol/l (1.2-5.8 pmol/l)

What is the most probable cause of her symptoms?

MRCP2-1282

A 40-year-old woman presents to the clinic with a three-month history of increasing fatigue, lethargy, and difficulty concentrating. She has also experienced nonspecific abdominal pain, resulting in weight loss due to a reduction in appetite. Despite the pain, she has not experienced any vomiting or diarrhea. She recently had to cut her holiday in Mexico short due to feeling unwell. On examination, she appears slim and tanned from her recent trip. Her vital signs are within normal limits, and her abdomen is soft and non-tender.

The following investigations were conducted:
– Hemoglobin: 128g/l (115-165)
– White blood cell count: 10.2 * 109/l (4.0-11.0)
– Sodium: 128 mmol/l (137-144)
– Potassium: 5.6 mmol/l (3.5-4.9)
– Urea: 10.8 mmol/l (2.5-7.0)
– Creatinine: 98µmol/l (60-110)
– Albumin: 38g/l (37-49)
– Alkaline phosphatase: 126U/l (45-105)
– ALT: 112U/l (5-35)
– Bilirubin: 12µmol/l (1-22)
– Alkaline phosphatase: 126U/l (45-105)
– Amylase: 826U/l (60-180)
– Calcium: 2.84mmol/l (2.20-2.60)

What is the most appropriate next step in making a diagnosis?

MRCP2-1283

A 65-year-old man is admitted to the Emergency Department after being found confused by his wife. He has problems with mobility and hypertension, and takes a number of medications. According to his wife, he has been increasingly chesty with a cough productive of bloodstained sputum over the past three days.
On arrival in the Emergency Department, his blood pressure is 150/90 mmHg, pulse 76 bpm and regular and temperature 37.8 °C. There are signs of left-sided consolidation on auscultation. He is drowsy and confused and suffers a short (30 s) tonic–clonic seizure just after you complete your physical examination.
Investigations:
Investigations Results Normal Values
Haemoglobin (Hb) 135 g/l 130–170 g/l
White cell count (WCC) 12.5 × 109/l 4–11 × 109/l
Platelets (PLT) 180 × 109/l 150–400 × 109/l
Sodium (Na+) 130 mmol/l 135–145 mmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Creatinine 95 µmol/l 50–120 µmol/l
Glucose 8.5 mmol/l 3.5–5.5 mmol/l
C-reactive protein (CRP) 210 mg/l < 5 mg/l
Chest X-ray: Left lower lobe consolidation.
Which of the following is the most appropriate intervention in addition to antibiotic therapy?

MRCP2-1284

A 43-year-old woman presented to the clinic with complaints of palpitation, tremor, and weight loss. She has no significant medical history and is not taking any regular medication.

During the physical examination, a palpable goitre, exophthalmos, and tremors of the outstretched hands were observed.

The thyroid function tests revealed:

– Free thyroxine (T4) 36 pmol/L (10-25)
– Free triiodothyronine (T3) 15 pmol/L (5-10)
– Thyroid-stimulating hormone 0.1mU/L (0.4-5.0)

What would be the initial treatment recommended to alleviate the symptoms?

MRCP2-1253

A 20-year-old man with a history of asthma presents to the Emergency Department with complaints of leg weakness and inability to walk after running a marathon the previous day. Upon examination, there is bilateral 3/5 weakness of the leg extensors. However, tone, reflexes, and coordination are unimpaired, and plantars are downgoing bilaterally. The straight leg raise and sensation to light touch and pain stimulus are unimpaired.

The blood tests reveal the following results: Hb 13.4g/dl, WBC 6.2 x 109/l, Na+ 136 mmol/l, K+ 2.9mmol/l, Urea 6.8 mmol/l, and Creatinine 104µmol/l.

What is the most appropriate treatment for this patient?

MRCP2-1269

A 32-year-old woman contacts the endocrinology nurse seeking advice. She has been experiencing vomiting for the past 24 hours and has been unable to take her regular medications due to this. She has a medical history of Addison’s disease and usually takes oral hydrocortisone and fludrocortisone. She denies any other symptoms apart from reduced oral intake and has not experienced dizziness on standing, blackouts, or diarrhea. Her temperature has been normal. She has IM hydrocortisone available at home. What is the most appropriate advice to give regarding her hydrocortisone?

MRCP2-1254

A 75-year-old man is admitted with severe diarrhoea. He reports having profuse diarrhoea for the past 5 days. He denies any blood or mucous in his stools. During examination, he appears to be peripherally shut down, with a blood pressure of 90/50 mmHg and a heart rate of 120 beats per minute. The following blood results are obtained:

– Hb: 130 g/l
– Na+: 110 mmol/l
– Platelets: 500 * 109/l
– K+: 3.1 mmol/l
– WBC: 15.2 * 109/l
– Urea: 19.5 mmol/l
– Neuts: 11.2 * 109/l
– Creatinine: 215 µmol/l
– Lymphs: 2.0 * 109/l
– CRP: 80 mg/l

The patient is diagnosed with hypovolaemic shock and is resuscitated with 0.9% saline boluses.

Later in the day, the patient presents with muscle weakness. Upon examination, spastic quadriparesis is noted.

What is the most likely cause of the patient’s symptoms?

MRCP2-1255

You are asked to assess a 36-year-old man who has just had a seizure on the Acute Medical Unit. He was admitted two days ago due to acute agitation in the Emergency Department. The patient reported a 10-year history of alcohol overuse and had not consumed any alcohol for 24 hours after a disagreement with his girlfriend. Prior to this, he had been drinking 4-6 litres of cider per day along with varying amounts of spirits. He was admitted for detoxification and given chlordiazepoxide, pabrinex, and fluids. He has no other medical history.

The nursing staff reports that the patient has not had any other seizures during this admission and has been consuming small amounts of food and drink today. However, he has been experiencing generalized body pain and became confused 2-3 hours ago. The seizure is tonic-clonic and self-terminates after 3 minutes.

Upon examination after the seizure, the patient is drowsy but responsive to voice. His oxygen saturation is 100% on 15 liters of oxygen via a non-rebreather mask, and his temperature is 37.2 ºC. His heart rate is 110 beats per minute, and his blood pressure is 126/72 mmHg. His chest is clear, abdomen is soft and non-tender, and there is no focal neurology.

You order repeat blood tests and arterial blood gas. What electrolyte abnormality is most likely to have caused his seizure?