MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1266

A 63-year-old woman presents for her diabetic review. She has type-2 diabetes and suffered an NSTEMI 3 months ago, resulting in a decrease in her ejection fraction. Her current medication includes metformin 500mg TDS, aspirin, statin, bisoprolol, and ramipril.

The patient’s pre-clinic blood results are as follows:

– HbA1c 59 mmol/mol (<42 mmol/mol)
– Urea 8.3 mmol/L (2.0 – 7.0)
– Creatinine 140 µmol/L (55 – 120)
– eGFR 32.8mL/min/1.73m²

Her BMI is 28.7kg/m², with a weight of 62 kg and a height of 147 cm. She recently attended a retinal screening appointment and was informed of pre-proliferative diabetic retinopathy changes. A follow-up appointment with the renal team regarding her diabetic nephropathy is scheduled for 2 weeks from now.

The patient’s main concern is experiencing hypoglycemia episodes, as she lives alone and would prefer to avoid increasing her risk of hypos if possible. What would be the most appropriate course of action regarding her oral anti-diabetic agents?

MRCP2-1251

A 52-year-old male presents at the diabetic clinic for his annual review. He has been diagnosed with diabetes and mild hypertension for four years and is currently taking gliclazide 160 mg bd, metformin 500 mg bd, rosuvastatin 10 mg od, and bendroflumethiazide 2.5 mg daily. During the consultation, he expresses concern about his deteriorating impotence, which has been ongoing for the past 12 months. Despite trying Viagra, he has not experienced any improvement. His wife is understanding, but he is becoming increasingly distressed about the situation. Upon examination, he has a BMI of 29 kg/m2, a blood pressure of 134/78 mmHg, and a pulse of 90 bpm. There is no evidence of neuropathy or retinopathy, and all pulses are palpable. He reports no history of joint pains.

The patient’s investigations reveal a HbA1c of 63 mmol/mol (20-46), fasting plasma glucose of 9 mmol/L (3.0-6.0), total cholesterol of 4 mmol/L (<2.5), serum testosterone of 6.5 nmol/L (9-35), plasma lutenising hormone of 0.5 mU/L (1-10), plasma follicle stimulating hormone of 0.9 mU/L (1-7), and plasma prolactin of 322 mU/L (<360). What further investigation would you recommend for this patient?

MRCP2-1267

A 28-year-old female patient visits the ENT clinic complaining of hoarseness that has persisted for three weeks despite adequate fluid intake. The patient was referred to the clinic by her general practitioner after a phone consultation. Upon examination, a non-painful goiter was observed. The patient denies any symptoms of thyroid dysfunction and reports feeling generally well. She has no difficulty speaking except for the hoarseness and does not experience any breathing difficulties. What is the best course of action to take in this case?

MRCP2-1252

A 54-year-old man presents to clinic after routine blood tests revealed a K+ level of 2.8 mmol/l. He has a history of angina and renal stones but reports feeling well. On examination, his chest is clear and abdomen is soft and non-tender. His vital signs are within normal limits and his ECG shows normal sinus rhythm. Further investigations reveal a urinary K+ level of 26 mmol/l (normal <20) and a creatinine level of 117 µmol/l. What is the most likely cause of his hypokalaemia?

MRCP2-1268

A 50-year-old truck driver presented to the endocrine clinic with complaints of decreased libido and low energy levels. He had a history of head injury 3 years ago, which required 24-hour observation in the hospital. On physical examination, his BMI was 40 kg/m2 and his general and systemic examination was unremarkable.

The following investigations were conducted:

– FT4: 8.1 pmol/l (11.5-22.7)
– TSH: 0.4 mU/l (0.35-5.5)
– FSH: 2.2 U/l (1.4-18.1)
– LH: 3.5 U/l (3.0-8.0)
– Testosterone: 6.8 nmol/l (8.4-28.7)
– IGF-1: 35 nmol/l (16-118)
– Prolactin: 880 mU/l (45-375)

Based on his clinical profile, what is the most likely diagnosis?

MRCP2-1237

A 70-year-old man with a history of high blood pressure, type 2 diabetes and hypercholesterolaemia was admitted to the emergency department with confusion. His daughter states that this has come on slowly over the last week and prior to this he had no memory problems. He currently takes metformin, ramipril, amlodipine and atorvastatin.

On examination, he smells strongly of urine and his mucous membranes appear dry. His abbreviated mental test score is 7 out of 10 and he is oriented in person but not in place or time. His heart rate is 95 per minute and his blood pressure is 105/62 mmHg. His chest is clear and has a soft ejection systolic murmur which does not radiate. His jugular venous pressure is not visible and he has mild ankle oedema. He has diffuse tenderness in the lower abdomen with no peritonism and normal bowel sounds. He has no focal neurology.

Investigation results are as follows:

Chest x-ray: Clear lung fields.

Urine dip:

Glucose +++
Blood +
Protein +
Leucocytes +
Nitrites +
Ketones +

Venous blood gas:

pH 7.43
BE – 1.5 mmol/l
HCO3 23 mmol/l
Glucose 34 mmol/l
Lactate 2.5 mmol/l

Full blood count:

Hb 120 g/l
Platelets 445 * 109/l
WBC 13 * 109/l

Renal function:

Na+ 151 mmol/l
K+ 5 mmol/l
Urea 10 mmol/l
Creatinine 137 µmol/l
Glucose 32 mmol/l
Ketones 2 mmol/l

What is the most appropriate initial resuscitation measure for this patient?

MRCP2-1238

A 67-year-old male was admitted with worsening agitation and confusion over the past week. He has a medical history of hypertension, ischaemic heart disease, and chronic back pain. His daughter noticed that he has lost approximately 1 stone in weight (currently weighs 71 kg), has been more fatigued over the last month, and has been drinking more water, which has led to urinary incontinence.

During examination, his heart rate was 108 beats/min, blood pressure was 95/42 mmHg, saturations were 94% on air, and respiratory rate was 20/min. He appeared dehydrated and had a Glasgow Coma Scale of 14.

The following blood results were obtained:

– Na+ 125 mmol/l
– K+ 5.0 mmol/l
– Urea 18 mmol/l
– Creatinine 180 µmol/l
– Blood glucose 34 mmol/l

A venous blood gas was performed, which showed:

– pH 7.32
– pCO2 4.6 kPa
– pO2 6.1 kPa
– HCO3 17 mmol/l
– BE -3.6 mmol/l

What is the most crucial treatment?

MRCP2-1239

A 35-year-old woman with a history of type 1 diabetes presents to the Emergency department with nausea and vomiting coupled with increased urinary frequency over the past 3 days. She has been progressively losing weight and reducing her insulin dose after starting empagliflozin prescribed to help her lose weight and reduce glucose fluctuations. She also admits to taking a Chinese herbal remedy for weight control.

Blood pressure is 100/70 mmHg, pulse is 88 beats per minute. pH is 7.25, glucose is 8.1 mmol/l, urine testing reveals ketones +++

What is the most likely diagnosis for this patient?

MRCP2-1240

A 16-year-old female presents with a six-month history of secondary amenorrhea and slight galactorrhea over the last three months. She had regular periods since menarche at the age of 11 until six months ago. She has been sexually active for approximately one year and has occasionally used condoms for contraception. She smokes five cigarettes daily and occasionally smokes cannabis. On examination, she appears clinically euthyroid, has a pulse of 70 bpm, and a blood pressure of 112/70 mmHg.

Investigations show:
– Serum estradiol 130 nmol/L (130-600)
– Serum LH 4.5 mU/L (2-20)
– Serum FSH 2.2 mU/L (2-20)
– Serum prolactin 6340 mU/L (50-450)
– Free T4 7.2 pmol/L (10-22)
– TSH 2.2 mU/L (0.4-5.0)

What is the most likely diagnosis?

MRCP2-1241

A 54-year-old female presents with galactorrhoea. Upon further questioning, she reports feeling extremely fatigued lately. She has no prior medical history and does not take any regular medications.

The following blood results were obtained:

Hb: 125 g/l
Platelets: 422 * 109/l
WBC: 9.2 * 109/l
Neuts: 6.2 * 109/l
Lymphs: 2.4 * 109/l
Na+: 132 mmol/l
K+: 3.8 mmol/l
Urea: 6.4 mmol/l
Creatinine: 41 µmol/l
CRP: 4 mg/l
Prolactin: 440 ng/dL (normal 5 – 40)

What diagnostic test will you order?