MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1214

A 72-year-old woman presents to the emergency clinic after her GP noticed low sodium levels in a routine blood test. Her electrolyte levels are as follows:

Na+ 120 mmol/L (135 – 145)
K+ 4.2 mmol/L (3.5 – 5.0)
Urea 5.6 mmol/L (2.0 – 7.0)
Creatinine 65 µmol/L (55 – 120)

A previous electrolyte check 2 years ago was unremarkable. However, she is currently asymptomatic and shows no signs of peripheral edema. On examination, her jugular venous pulse is visible but not raised, and her mucous membranes are moist. Heart sounds are normal, and her chest is clear on auscultation. Her heart rate is 68 beats per minute, and her blood pressure is 115/75 mmHg.

Further tests reveal a serum osmolality of 275 mOsm/kg (280-285), urine sodium of 42 mEq/L (<20), and urine osmolality of 175 mOsm/kg (50-1200). What is the most appropriate initial management step to increase her sodium levels?

MRCP2-1201

A 50-year-old man presents to the Endocrinology Clinic for evaluation. His GP referred him due to a gradually enlarging mass in the left lobe of the thyroid. The patient is worried about the possibility of having cancer. What factors could potentially increase the probability of thyroid malignancy in this individual?

MRCP2-1202

A 47-year-old woman presents to the endocrinology outpatient service with incidental hypercalcaemia on a routine blood test. She has no significant medical history.

On examination, there are no notable findings.

Lab results:

– Parathyroid hormone: 8.2 pmol/L (normal range: 1.6 – 6.9)
– Calcium: 2.78 mmol/L (normal range: 2.20-2.6)
– Vitamin D: 72 nmol/L (normal range: >50)
– Urea: 4.5 mmol/L (normal range: 2.0 – 7.0)
– Creatinine: 70 µmol/L (normal range: 55 – 120)

What is the most likely cause of these findings?

MRCP2-1203

A 57-year-old female patient presents to you with a complaint of tiredness that has been ongoing for three years. During the examination, you find an elevated calcium concentration in her blood. She has been feeling depressed since the death of her elderly parents. Her elder brother and his son were diagnosed with a calcium problem six years ago, but they have not received any treatment. She takes only atenolol for hypertension and does not take any supplements. Her blood pressure is 148/96 mmHg, and no other abnormalities are noted during the examination.

The following investigations were conducted:
– Serum sodium: 138 mmol/L (137-144)
– Serum potassium: 3.8 mmol/L (3.5-4.9)
– Serum urea: 7.1 mmol/L (2.5-7.5)
– Serum calcium: 2.76 mmol/L (2.2-2.6)
– Serum phosphate: 1.0 mmol/L (0.8-1.4)
– Alkaline phosphatase: 100 U/L (45-105)
– PTH concentration: 4.4 pmol/L (0.9-5.4)
– Urine calcium: 1.2 mmol/24 hrs (2-10)

What treatment plan would you recommend for this patient?

MRCP2-1204

A 50-year-old woman was incidentally found to have hypercalcemia. She presented with no symptoms and had a normal physical examination. Further investigations revealed the following results:

– Serum sodium: 138 mmol/L (137-144)
– Serum potassium: 4.1 mmol/L (3.5-4.9)
– Serum urea: 3.8 mmol/L (2.5-7.5)
– Serum creatinine: 88 µmol/L (60-110)
– Serum corrected calcium: 2.76 mmol/L (2.2-2.6)
– Serum phosphate: 0.86 mmol/L (0.8-1.4)
– Serum alkaline phosphatase: 86 U/L (45-105)
– Plasma parathyroid hormone: 5.3 pmol/L (0.9-5.4)
– 24-h urinary calcium: 0.5 mmol/24hr (2.5-7.5)

What is the most likely diagnosis?

MRCP2-1195

A 32-year-old woman with a history of Graves’ disease presents to the endocrinology clinic for follow-up. She underwent radioiodine treatment a year ago and has since remained clinically and biochemically euthyroid. Her initial symptoms of weight loss and insomnia have not recurred. Her GP ordered blood tests prior to the appointment, which revealed a TSH level of 2.6 and a free T4 level of 8.2mg/dl. The patient has recently discontinued oral contraceptive use and is planning to conceive. What is the most appropriate management plan?

MRCP2-1196

You are requested to assess a 63 year-old Caucasian man who is currently admitted to the medical admissions unit for treatment of a community acquired pneumonia affecting his left lower lobe. Prior to admission, he had a history of excessive alcohol consumption but has been abstinent for the past four days.

During his hospital stay, the patient’s blood glucose levels have been consistently elevated, leading to a new diagnosis of type two diabetes. Additionally, the admission consultant noted the presence of Cushingoid features and ordered an overnight low dose dexamethasone suppression test. The results of the test are as follows:

– 8am Cortisol after 1 mg dexamethasone at 11pm the previous day: 438 nmol/L
– Reference range for serum cortisol: 170-540 nmol/L

What would be the most appropriate next step in investigating this patient’s condition?

MRCP2-1197

A 55-year-old truck driver has been referred to secondary care for poorly controlled type 2 diabetes mellitus. Despite being diagnosed six years ago, he has not made any lifestyle changes and now has diabetic nephropathy and proliferative retinopathy. He also has a history of ischaemic heart disease, hypertension, hypercholesterolaemia, osteoarthritis, and gout. His current medications include aspirin, ramipril, simvastatin, naproxen, co-codamol, lansoprazole, metformin, gliclazide, and pioglitazone. He smokes 20 cigarettes per day and drinks 15 units of alcohol per week. On examination, he is obese with a BMI of 38 kg/m and has a blood pressure of 148/88 mmHg. His investigations reveal elevated levels of urea, creatinine, and HbA1c. What is the most appropriate management step for this patient?

MRCP2-1198

A 32-year-old woman with no prior medical history visits her GP complaining of feeling anxious and on edge for the past month. She also experiences sweating and hand tremors that are affecting her work as a teacher. She occasionally experiences abdominal bloating, which she manages with herbal tea.

During the examination, the patient appears flushed and tremulous but alert. There is no goitre or skin rash present. A small non-tender mass is palpable on the left side of her pelvis, with normal bowel sounds overlying. Her visual fields and cranial nerve exams are normal. A thyroid scintigraphy shows normal uptake, and an MRI scan is pending.

TSH levels are 5.0 mU/L (range 0.4-4.0), and T4 levels are 28 pmol/l (range 9-24). Urine HCG is negative. What is the most likely diagnosis?

MRCP2-1199

A 28-year-old woman presents to the endocrine clinic as an urgent referral from her GP. She has been experiencing flu-like symptoms and pain in the front of her neck, and is now extremely agitated and anxious. Her husband reports that she is having difficulty sleeping due to worry about a potential serious condition. She is currently taking the combined oral contraceptive pill.

During examination, her blood pressure is 145/82 mmHg, pulse is 95 and regular, and she has a fine tremor with slightly sweaty hands. Heart sounds are normal, her chest is clear, her abdomen is soft and non-tender, and her BMI is 22. She experiences tenderness over the thyroid during palpation of the neck.

Investigations reveal a haemoglobin level of 119 g/L (115 – 160), white cell count of 9.3 ×109/L (4 – 11), platelets of 198 ×109/L (150 – 400), sodium of 139 mmol/L (135 – 146), potassium of 4.0 mmol/L (3.5 – 5), and creatinine of 100 µmol/L (79 – 118). Her TSH level is 0.2 IU (0.5 – 5).

What is the most appropriate treatment for her symptoms?