MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine
MRCP2-1256
A 70-year-old man is admitted onto the ward with confusion. He has a past medical history of an ischaemic stroke 4 months ago. His drug history includes atorvastatin, ramipril and clopidogrel. He lives alone and has no package of care.
On examination, he has very poor mobility. His heart rate is 105 bpm and blood pressure 105/75 mmHg. His JVP is not visible.
What could be the possible reason for the hypernatraemia?
MRCP2-1257
A 44-year-old woman visits her doctor with a lump in her neck. Following an examination and initial tests, she is urgently referred to the local endocrine multidisciplinary team, who conduct further scans and diagnose thyroid cancer. She subsequently undergoes a thyroidectomy, which is uncomplicated. However, she experiences a sudden onset of hoarseness in her voice post-surgery. What is the most suitable course of action now?
MRCP2-1258
A 45-year-old female is admitted with an overdose of gliclazide. She reports taking ten 40mg tablets about three hours ago following an argument with her partner. She has a medical history of type 2 diabetes mellitus, self-harm, and psychotic depression. Her medication list includes gliclazide and venlafaxine.
Upon examination, she appears sweaty and clammy, and her heart rate is 120 bpm. Her Glasgow coma score is 13 (M6, V4, E3). Her plasma glucose level is 3.5 mmol/l.
You administer 100 ml of 20% dextrose, which initially raises her blood glucose level to 5.5 mmol/l. However, it quickly drops back down to 3.2 mmol/l despite a continuous infusion of 20% dextrose.
What course of treatment will you provide?
MRCP2-1259
A 44-year-old man is referred to the Endocrinology clinic by his GP due to asymptomatic hypercalcaemia found on routine blood tests. He has a medical history of hypertension and is currently taking amlodipine, ramipril and chlorthalidone.
What is the most likely cause of hypercalcaemia in this patient?
MRCP2-1260
A 40-year-old man presents to endocrinology clinic with concerns about gynaecomastia. He had previously seen his GP for this issue, which was initially thought to be related to alcohol excess and possible liver involvement. However, after stopping alcohol and normal liver function tests, this diagnosis was ruled out. The patient has no significant medical history except for a tibial fracture a year ago and a recent diagnosis of migraines. He takes paracetamol for the migraines but finds it ineffective, especially at night. Upon further questioning, he reports difficulty maintaining an erection. On examination, he has gynaecomastia but is otherwise unremarkable. Repeat blood tests in the clinic reveal low morning serum testosterone levels, with normal FSH and LH. What additional investigation would be most helpful in making a diagnosis?
MRCP2-1261
A 55-year-old male presents with 48 hours of general malaise. 20 years ago, he underwent a resection of a pituitary mass and has since been compliant on desmopressin, levothyroxine and hydrocortisone, up until his last dose earlier in the morning. He has no other past medical history. His wife reports the patient to have had reduced oral intake for the past 2 days while he has been unwell. He has no reported head injuries, rigors or pyrexia.
On examination, his GCS is E3 V2 M5. He is cool peripherally and a temperature demonstrates 33.4 degrees under his tongue. His spot blood glucose is 2.2 mmol/l. His blood pressure is 86/50 mmhg heart rate 110/min and sinus rhythm. Blood tests demonstrate a sodium of 158 mmol/l and potassium of 4.2 mmol/l. What is your first action(s)?
MRCP2-1262
You are requested to evaluate a 50-year-old male patient who has been seen four times in the past seven days due to persistent hyperkalaemia on his blood tests. The patient has been admitted for five weeks under the care of surgeons following an AP resection of sigmoid carcinoma complicated by a superficial wound infection that required a vacuum dressing. During the previous three medical reviews, the patient had a serum potassium level greater than 6.5 mmol/l and was treated with insulin-dextrose and calcium gluconate.
The patient’s medical history includes type 2 diabetes mellitus, non-alcoholic steatohepatitis, and neuromyelitis optica diagnosed six years ago, which was stable on the last review two months ago. The patient’s regular medications include gliclazide 80mg BD, Lantus (insulin glargine) 15 units OD, prednisolone 15 mg OD, and baclofen 10 mg QDS. During this review, the patient is alert and comfortable, with a blood pressure of 135/82 mmHg, heart rate of 90/min, and sinus rhythm.
A repeat CT abdomen and pelvis demonstrates appropriate wound healing with no local collections at the resection site. No other abdominal pathology is noted.
What is the most probable diagnosis?
MRCP2-1263
A patient with type 1 diabetes mellitus is urgently referred to the endocrinology consultant from a Dose Adjustment For Normal Eating (DAFNE) course. The nurse in the course was concerned as the patient, who is in his mid-30s, has experienced three episodes of hypoglycaemia in the past nine months, requiring assistance from his wife to increase his blood glucose levels. He follows a basal bolus regimen of long acting insulin once a night and short acting insulin three times a day, and works in a restaurant. He is an ex-smoker and drinks very little alcohol. Besides adjusting the insulin dose, what is the most appropriate course of action?
MRCP2-1264
A 24-year-old woman is brought into the emergency department by ambulance with her dad, who found her unconscious on the bathroom floor just half an hour ago. The dad had last seen her 4 hours previously and reports she was well at this time. She has a past medical history of depression and was last admitted 6 months ago with a paracetamol overdose. She has otherwise been well in herself and suffers no other medical conditions that dad is aware of. Her GCS on arrival is 8. She is found to be severely hypoglycaemic at 2.2mmol/L and is treated with IV dextrose.
As the medical registrar on call, you have been asked to assess her. She has now been on a dextrose infusion for 45 minutes with no minimal improvement. The examination is grossly normal besides a tachycardia of 110 bpm and GCS of 10/15 (M4, E3, V3). She is maintaining her own airways. Up-to-date glucose is 2.9 mmol/L, and her C-peptide and insulin are both elevated. You ask that she be given 50mL of 50% glucose IV, but she remains hypoglycaemic despite this.
What treatment options should be considered for this 24-year-old woman?
MRCP2-1265
An 80-year-old woman presents to the emergency department with complaints of confusion, dizziness, and weakness. She has experienced similar episodes in the past three months. Her medical history includes type 2 diabetes mellitus for 15 years, hypertension, and hyperlipidemia. She is currently taking metformin and glimepiride for her diabetes.
Upon examination, her vital signs are as follows: temperature 37ºC, blood pressure 120/80 mmHg, heart rate 80/min, and respiratory rate 18/min. Physical examination reveals no abnormalities.
Blood tests are ordered, and her finger-stick glucose level is found to be 2.5 mmol/L. The patient is given glucagon IM and 50 ml of 50% dextrose IV, but she remains confused. A repeat finger-stick glucose level is 2.8 mmol/L. Serum insulin and C-peptide levels, drawn before dextrose administration, are elevated.
What is the most appropriate next step in managing this patient?