MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1166

A 25-year-old woman presents with worsening hirsutism and is referred by her primary care physician. She has noticed increased facial and truncal hair growth since she began menstruating at age 15. She had been taking oral contraceptives and had regular periods until she stopped due to weight gain a year ago. She has only had one period in the past three months.

During the examination, her pulse was 82 beats per minute, blood pressure was 128/82 mmHg, and her BMI was 30.4 kg/m2. The following laboratory results were obtained: Free T4 12.8 pmol/L (10-22), TSH 1.2 mU/L (0.4-5), 17 Beta-oestradiol 254 pmol/L (130-850), LH 11.4 mU/L (2-10), FSH 6.2 mU/L (2-10), Prolactin 610 mU/L (50-450), Testosterone 3.2 nmol/L (<3), Dehydroepiandrostenedione sulphate (DHEAS) 17.2 pmol/L (2-10), and 17-Hydroxyprogesterone 3.2 pmol/L (2-20). What is the most likely diagnosis?

MRCP2-1167

A 72-year-old man who has been on long term digoxin therapy presents to the clinic with complaints of palpitations at rest. During examination, his blood pressure is 140/80 mmHg and his resting pulse is 95/min. Thyroid gland examination is unremarkable. Further investigations reveal the following results:

– Haemoglobin (Hb): 122 g/l (normal range: 115-155 g/l)
– White cell count (WCC): 5.8 × 109/l (normal range: 4.0-11.0 × 109/l)
– Platelets (PLT): 175 × 109/l (normal range: 150-400 ×109/l)
– Sodium (Na+): 140 mmol/l (normal range: 135-145 mmol/l)
– Potassium (K+): 4.5 mmol/l (normal range: 3.5-5.0 mmol/l)
– Creatinine (Cr): 128 μmol/l (normal range: 50-120 μmol/l)
– Thyroid-stimulating hormone (TSH): 0.4 U/l (normal range: 0.5-4.5 U/l)
– Thyroid autoantibodies: Negative
– Interleukin 6 (IL-6): Elevated

You decide to switch his digoxin to another medication. What is the primary treatment approach in this scenario?

MRCP2-1168

A 32-year-old woman who is 32 weeks’ pregnant presents to the clinic with complaints of increasing fatigue, mood swings, exhaustion particularly in the evenings, and episodes of heart palpitations. Her primary care physician has attributed these symptoms to the normal stresses and strains of pregnancy. Upon examination, she appears fatigued, her blood pressure is 126/80 mmHg, and her resting pulse is 92/min. You observe that she has sweaty palms and a small, smooth goiter upon palpation. The following investigations were conducted:

Haemoglobin (Hb) 112 g/l 115–155 g/l
White cell count (WCC) 5.8 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 178 × 109/l 150–400 × 109/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 98 µmol/l 50–120 µmol/l
Thyroid-stimulating hormone (TSH) < 0.05 µU/l 0.17–3.2 µU/l What is the most probable diagnosis?

MRCP2-1169

A 16-year-old boy visits his family doctor, concerned about his delayed puberty compared to his peers. He reports no other symptoms and has a clean medical history. Upon examination, he appears tall but lacks muscle development and facial hair. His testicles measure 4 cm2 on orchidometry, and there is minimal pubic hair growth. The following investigations were conducted:

Luteinising hormone (LH) 0.7 mIU/ml 1.3–8 mIU/ml
Testosterone 3 nmol/l 10–30 nmol/l

What is the most probable diagnosis?

MRCP2-1170

A 28-year-old man is referred to the Endocrinology Clinic by his primary care physician. He has had two episodes of fainting over the past three months. There is also a history of increased thirst and urination, which has been accompanied by gradual weight loss.

On further questioning, family history reveals no useful information. You elect to admit him for a period of fasting. The morning after admission, some 14 hours without food, he complains of feeling dizzy.

Investigations reveal the following:

Glucose 2.8 mmol/l < 7 mmol/l
Insulin 2 mU/l with decreased proportion of pro-insulin
C-peptide Decreased
Cortisol 400 nmol/l
9 am: 140–500 nmol/l
Midnight: 50–300 nmol/

Which of the following diagnoses fits best with this clinical picture?

MRCP2-1171

A 42-year-old woman with a lengthy history of Type 1 diabetes arrives at the Emergency Department with a sudden onset of diplopia. Despite basal bolus insulin, her diabetes is poorly controlled, and a recent HbA1c test showed a reading of 76 mmol/mol (9.1%). She has previously undergone laser therapy for diabetic retinopathy, experiences numbness in both feet, and has recovered from a left common peroneal nerve palsy. During the examination, her right eye is looking down and out, there is a ptosis on the right-hand side, and the pupil appears unaffected.
Investigations:
Hb 120 g/l
WCC 7.1 x109/l
PLT 201 x109/l
Na+ 137 mmol/l
K+ 5.0 mmol/l
Creatinine 132 micromol/l
Glucose 9.3 mmol/l
ESR 9 mm/1st hour
What is the most probable underlying cause of her cranial neuropathy?

MRCP2-1172

A 59-year-old woman with poorly controlled type II diabetes presents to the Emergency Department with burning pain and weakness in her left thigh after starting insulin therapy. She is not due for follow-up in clinic for two months. On examination, she has a blood pressure of 145/90 mmHg, and neurological findings reveal weakness and wasting of the left quadriceps, loss of the left knee jerk, and slightly diminished sensation over the medial aspect of the thigh. Her HbA1c is 64 mmol/mol (8.0%), and other investigations are within normal limits. Based on these findings, what is the most likely diagnosis?

MRCP2-1141

A 19-year-old male presents with a two day history of vomiting, general lethargy and dizziness.

Over the last six months he had lost 5 kg in weight, had a reduced appetite and had been feeling increasingly lethargic. He had no past medical history of note, was a non-smoker and did not take any regular medications. His elder brother was well and there was no significant family history.

On examination, he was comfortable at rest, appeared slightly dehydrated, was apyrexial, had a body mass index of 19 kg/m2 and oxygen saturations on air of 98%. His blood pressure was 110/70 mmHg and fell to 90/60 mmHg on standing. His pulse was 80 beats per minute regular and auscultation of the heart and chest were normal. No abnormalities were detected on abdominal or CNS examination.

Investigations revealed:

– Haemoglobin 110 g/L (130-180)
– Mean cell volume 90 fL (80-100)
– White cell count 9.2 ×109/L (4-11)
– Neutrophils 5.0 ×109/L (1.5-7)
– Lymphocytes 3.2 ×109/L (1.5-4)
– Eosinophils 0.6 ×109/L (0.04-0.4)
– Serum sodium 132 mmol/L (135-145)
– Serum potassium 5.5 mmol/L (3.5-5.1)
– Serum urea 10.2 mmol/L (2.5-7.5)
– Serum creatinine 120 µmol/L (60-110)
– Plasma glucose 4.2 mmol/L (3.0-6.0)
– Free T4 12.0 pmol/L (10-22)
– TSH 1.0 mu/L (0.4-5)
– Urinalysis Ketones +

Which of the following is the most appropriate investigation for this patient?

MRCP2-1157

A 29-year-old woman presents to the Endocrinology Clinic for review. She recently suffered a fall whilst at dancing and was knocked out for a few minutes.
Since then, over the past few weeks, she has suffered polyuria and polydipsia. She has no past medical history of note, and her only medication is the oral contraceptive pill.
On examination, her BP is 125/72 mmHg, with pulse 83/min and regular. She has a postural drop of 15 mmHg on standing. Her BMI is 21. Neurological assessment is unremarkable.
Investigations:
Investigation Result Normal values
Haemoglobin (Hb) 131 g/l 135 – 175 g/l
White cell count (WCC) 8.1 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 191 × 109/l 150 – 400 × 109/l
Sodium (Na+) 146 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.4 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 142 µmol/l 50 – 120 µmol/l
Urea 9.1 mmol/l 2.5 – 6.5 mmol/l
Glucose 5.4 mmol/l 3.9 – 7.1 mmol/l
Corrected calcium (Ca2+) 2.21 mmol/l 2.2 – 2.7 mmol/l
Which of the following is the most appropriate next investigation?

MRCP2-1142

A 16-year-old girl from a traveller family presents to the clinic with concerns about her pubertal development. She has not yet experienced any secondary sexual hair growth or started her periods. As an infant, she underwent surgery to repair bilateral inguinal hernias. On examination, her height is 167 cm, blood pressure is 122/72 mmHg, and BMI is 21. Breast development appears normal, but there is no pubic or axillary hair. Laboratory tests reveal a hemoglobin level of 124 g/L, white blood cell count of 8.0 ×109/L, platelet count of 180 ×109/L, sodium level of 137 mmol/L, potassium level of 4.4 mmol/L, and creatinine level of 110 µmol/L. Based on this information, what is the most likely diagnosis?