MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1158

A 52-year-old woman presents to the Endocrinology Clinic with recently diagnosed type II diabetes. She reports leading a healthy lifestyle and is surprised by the diagnosis. Her past medical history includes hyperlipidemia, which is managed with atorvastatin.
On examination, her blood pressure is 140/80 mmHg and her heart rate is 72 bpm. Her cardiorespiratory examination is unremarkable, although she appears to be fatigued. Her abdomen is soft and non-tender. There is mild swelling of her ankles and she reports having to loosen her shoes due to discomfort.
Investigations:

Haemoglobin (Hb) 135 g/l 120 – 160 g/l
White cell count (WCC) 6.2 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 250 × 109/l 150 – 400 × 109/l
Sodium (Na+) 140 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 90 μmol/l 50 – 120 µmol/l
Random glucose 11.5 mmol/l 3.9 – 7.1 mmol/l

Which initial investigation would be most appropriate to confirm this patient’s likely underlying diagnosis?

MRCP2-1143

A 14-year-old female presents with primary amenorrhoea.

She is accompanied by her mother who explains that she has also lost approximately 10 kg of weight over the last year and has occasional episodes of diarrhoea. She has recently become a vegetarian and tends to favour wheat snacks and bread.

Her progress at school has been excellent, she plays the piano in the school orchestra and she regularly goes jogging several times a day. She has a younger brother who is well and her mother and maternal aunt have a past history of hyperthyroidism. Her parents divorced about two years ago and she sees her father infrequently. She takes no medication.

On examination she is thin with a BMI of 16.6 kg/m2 and appears phenotypically female. She has normal breast development with no galactorrhoea to expression, has absence of axillary and scanty pubic hair.

Investigations reveal the following:

Plasma oestradiol 70 pmol/L (130-550)

LH 3.5 mU/L (2-10)

FSH 4.0 mU/L (2-10)

17 Hydroxyprogesterone 5.2 nmol/L (3-15)

Free T4 12.4 pmol/L (10-22)

TSH 2.2 mU/L (0.4-5)

Prolactin 520 mU/L (50-500)

What is the most likely diagnosis?

MRCP2-1144

A 22-year-old female student presents with symptoms of weight gain and depression. She started university six months ago and three months ago sought treatment for worsening facial acne. Although topical tetracycline improved her acne, she has since become increasingly depressed, struggles with coursework, and experiences physical difficulty getting out of bed in the mornings. She has also noticed a weight gain of approximately 5 kg and menstrual irregularity. On examination, she has mild facial acne, a blood pressure of 128/86 mmHg, and a BMI of 32.1 kg/m2. Laboratory investigations reveal normal full blood count and electrolytes, a glucose level of 5.6 mmol/L (3.0-6.0), oestradiol level of 100 pmol/L (>130), LH level of 8.4 (1-10), and FSH level of 3.4 (1-10). What is the most appropriate next step in managing this patient?

MRCP2-1145

A 36-year-old female presents with a 2-year history of weight gain, hirsutism, and hypertension. She has also experienced irregular periods over the last 2 years and has not had a period in the last 2 months. On examination, she has a BMI of 32.4, a reddish complexion, abdominal striae, and difficulty rising from a squatting position. Her blood pressure is 168/98 mmHg.

The following investigations were conducted:
– U+E: Normal
– FBC: Normal
– Plasma glucose: 12.1 mmol/L (3.0-6.0)
– Thyroxine: 12.4 pmol/L (10-22)
– TSH: 0.85 mU/L (0.4-5)
– Oestradiol: <80 pmol/L (130-510)
– LH: 4.2 mU/L (2-10)
– FSH: 2.1 mU/L (2-10)
– 9 am Cortisol: 550 nmol/L (200-550)
– ACTH (morning): 45 (8-50)
– Midnight Cortisol: 420 nmol/L (<180)
– ACTH (evening): 35 (8-20)
– 24 hr Urine free cortisol: 580 nmol/d (90-290)
– Chest x Ray: Normal
– ECG: LVH
– Cortisol at end of low dose dexamethasone test (48 hrs 0.5 mg qds): 210 nmol/L
– Cortisol at end of high dose dexamethasone test (48 hrs 2 mg qds): 150 nmol/L
– MRI of pituitary: Normal

Which of the following apply to this patient?

MRCP2-1146

A 50-year-old male with diabetes presented at the diabetic clinic for his annual review. He had been diagnosed with diabetes eight years ago and had been attending clinic regularly. He was also receiving treatment for hypertension and was taking metformin 500 mg tds, gliclazide 80 mg daily, atorvastatin 10 mg/d, ramipril 10 mg/d and bendroflumethiazide 2.5 mg/d. On physical examination, he was found to be obese, weighing 130 kg, and had striae in the abdomen.

Further investigations revealed that his HbA1c was 65 mmol/mol (20-46) or 8.1% (3.8-6.4) and his fasting glucose was 9 mmol/L (3.0-6.0). His 24-hour urine free cortisol was 354 mmol/day (<250) and his 9am plasma ACTH was 4 ng/dL (10-50). A CT scan of his abdomen showed a 3 cm right adrenal mass. What is the nature of the adrenal mass?

MRCP2-1147

A 72-year-old man presented with general malaise and nausea. He was a retired farmer who had kept mostly sheep on his farm. He had returned from a holiday in Spain two weeks ago and had been feeling increasingly fatigued since then. He had also experienced poor appetite and an 8 kg weight loss over the past three months. He had a history of hypothyroidism and was taking thyroxine 100 mcg daily. He smoked five cigarettes per day and usually drank about 12 units of alcohol daily, but had consumed more alcohol than usual while on holiday. On examination, he appeared dehydrated, sun-tanned, and slightly confused, with a pulse of 92 bpm regular, a temperature of 37.2°C, and a blood pressure of 100/80 mmHg. His cardiovascular and respiratory examination were unremarkable, but he had a slight liver edge on palpation. Neurological examination was normal. Investigations revealed serum sodium of 125 mmol/L, serum potassium of 5.6 mmol/L, serum corrected calcium of 2.73 mmol/L, serum standard bicarbonate of 15 mmol/L, serum urea of 22 mmol/L, and plasma TSH of 6 mU/L. What is the most likely diagnosis?

MRCP2-1148

A 28-year-old female presents with a three month history of weight loss and general lethargy.

She has a five year history of Type 1 diabetes for which she has been treated with basal bolus insulin consisting of short acting insulin thrice daily and long acting insulin in the evenings.

Commensurate with her weight loss of 5 kg over the last three months she has noticed that she has recently encountered more hypoglycaemic events and has reduced her insulin requirements from 60 units per day to 38 units daily.

She takes no medication other than the oral contraceptive pill. She is a non-smoker and denies use of any illicit substances.

On examination she has a BMI of 21.2 kg/m2 and appears comfortable. Her pulse is 68 beats per minute regular and her blood pressure is 118/70 mmHg. There are no specific abnormalities of the chest, heart or abdomen but she has a slight purplish-yellow, non-tender 2-3 cm well circumscribed papules on both shins.

Investigations reveal:

Urinalysis Normal –
Haemglobin 12.1 g/dL (11.5-16.5)
White cell Count 5 ×109/L (4-11)
Random glucose 10.2 mmol/L (<11.1)
HbA1c 50 mmol/mol (20-46)
6.7% (3.8-6.4)
Plasma Sodium 135 mmol/L (137-144)
Plasma Potassium 4.5 mmol/L (3.5-4.9)
Plasma Urea 5 mmol/L (2.5-7.5)

What is the most appropriate investigation for this patient?

MRCP2-1149

A 25-year-old female presents with a two year history of secondary amenorrhoea and a six year history of facial hirsutism.

Examination reveals normal female secondary sexual characteristics with mild facial hair and hair extending up to the umbilicus and tops of thighs.

Investigations reveal:

Oestradiol concentration 65 pmol/L (130-450)

LH 3.2 mU/L (3-10)

FSH 3.5 mU/L (3-10)

Prolactin 320 mU/L (<450) Testosterone 3.4 pmol/L (<3) Which investigation from the following list may provide useful diagnostic information?

MRCP2-1150

A 50-year-old male presents with a one-year history of impotence and reduced shaving frequency. These symptoms have gradually developed over time and he has no libido or erections. He also shaves only once a week compared to his previous daily routine. In addition, he has been experiencing joint aches and lethargy with reduced energy levels. He has no medical history except for an appendicectomy at the age of 20, takes no medication, and is married with no children. He drinks 20 units of alcohol per week and smokes five cigarettes daily.

During examination, he appears slightly pigmented with gynaecomastia and fine skin with scant facial, pubic, and axillary hair. Testicular examination reveals a size of approximately 15 ml bilaterally with no masses felt. Cardiovascular, respiratory, and abdominal systems are normal, and there are no abnormalities noted on joint movements with a full range of motion.

The following investigations were conducted:
– Prolactin: 370 mU/L (50-450)
– Testosterone: 3.5 nmol/L (10-30)
– LH: 2.1 mU/L (2-10)
– FSH: 2 mU/L (2-10)
– Free T4: 12.8 pmol/L (10-22)
– TSH: 2.1 mU/L (0.4-5)

What is the most important investigation to determine the underlying diagnosis for this patient?

MRCP2-1151

A 25-year-old man presents to the Endocrinology Clinic with bilateral gynaecomastia. He reportedly had surgery as a child to correct bilateral undescended testes.

On examination, he is tall, with increased arm and leg length. He does have evidence of bilateral breast enlargement, with small testes bilaterally. Apparently, there have been problems with self-esteem and social anxiety at work, and he is now seeking medical advice.

What would be the most appropriate investigation in this case?