MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1121

A 60-year-old man presents to hospital with a four day history of fatigue, muscle pains, a fever and pain in the front of his neck. Three weeks ago he had an upper respiratory tract infection which he treated himself with paracetamol and oral decongestants. He did not receive any antibiotics. His medical history is unremarkable except for occasional use of antihistamines during the summer.

During examination, he appears restless with a slight resting tremor. He has a temperature of 38.2°C, a pulse rate of 120 per minute which is regular and normal in character and a blood pressure of 130/80 mmHg. Heart sounds 1 and 2 were present with no added sounds and his chest was clear on auscultation. His abdomen was soft and non-tender with no organomegaly. Neurological examination was unremarkable apart from the slight resting tremor. Neck examination reveals a diffusely enlarged and tender thyroid gland.

Blood tests are requested and the results are as follows:

Hb 14.2 g/dl
Platelets 380 * 109/l
WBC 9.1 * 109/l
ESR (Westergren) 96 mm/1st hour Normal range 0-30
Free T4 210 nmol/l
Free T3 190 nmol/L
Plasma TSH <0.05 mU/l Which investigation is most likely to be useful in establishing the diagnosis?

MRCP2-1137

A 30-year-old female of Bangladeshi origin presents with a four-month history of weight loss and fatigue. She returned to the United Kingdom three months ago after spending a year in Bangladesh due to ill health. She has no significant medical history, is a non-smoker, has no alcohol intake, and has two children. On examination, she has a BMI of 20 kg/m2, pigmentation of the palmar creases and buccal mucosa, a pulse of 77 bpm, and a blood pressure of 100/62 mmHg. Laboratory investigations reveal low haemoglobin and MCV, elevated white cell count, and high ESR. Her 9am plasma cortisol level is also low. What would be the most appropriate investigation to establish the diagnosis in this patient?

MRCP2-1122

A 38-year-old woman comes to your clinic complaining of feeling warm and more anxious than usual. She had a cold three weeks ago. During the examination, you notice a new tender goitre.

You order blood tests, including thyroid function tests, which are shown in the table below.

Thyroid stimulating hormone (TSH) 0.2 mU/L (0.5-5.5)
Free thyroxine (T4) 25 pmol/L (9.0 – 18)

What thyroid scintigraphy results do you anticipate based on the probable underlying diagnosis?

MRCP2-1138

A 32-year-old woman with a history of previous injury in a car accident comes to the clinic with her husband. He looks after her as she has been left with a left arm and leg weakness after a head injury and intracranial bleeding. She also has migraines for which she takes sumatriptan. They complain that she is constantly thirsty and drinks several liters of water and juice each day. Her mother has significant chronic illness, suffering from chronic left ventricular failure.

Investigations:

Haemoglobin 120 g/l 120–160 g/l
White cell count (WCC) 6.2 × 109/l 4–11 × 109/l
Platelets 220 × 109/l 150–400 × 109/l
Sodium (Na+) 148 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine 130 µmol/l 50–120 µmol/l
Bicarbonate 24 mmol/l 24–30 mmol/l
Plasma osmolality 355 mosmol/kg 280–295 mosmol/kg
Urine osmolality 280 after water deprivation,
rises to 820 after DDAVP

What is the most likely diagnosis?

MRCP2-1123

A 72-year-old man visits the falls clinic to discuss his osteoporosis medication. He has been taking weekly alendronate but is experiencing severe gastro-oesophageal reflux symptoms and has been hospitalized with coffee ground vomiting in the last three months. His recent DEXA scan shows a T score of -4.5 for the femoral neck. You decide to initiate denosumab treatment. What accurately describes the mechanism of action of denosumab?

MRCP2-1124

A 35-year-old woman presents with a two week history of feeling generally unwell, a 3 kg weight loss and suffering palpitations. She has otherwise been very well.

The only medication that she receives is an oral contraceptive. She is a non-smoker and drinks approximately 14 units of alcohol weekly. She is employed as an auxillary nurse and is single.

On examination she is apyrexial with a pulse of 98 beats per minute regular and a blood pressure of 124/80 mmHg and a BMI of 24.5 kg/m2. She has a slight tremor of the outstretched hands but no eye signs. She is noted to have a tender moderately enlarged goitre, with no audible bruit. No other abnormalities are noted.

Investigations reveal:

Full blood count Normal –

Urea and electrolytes Normal –

Glucose 5.5 mmol/L (3.0-6.0)

ESR 50 mm/hr (1-10)

Free thyroxine 27.9 pmol/L (10-22)

TSH 0.02 mU/L (0.4-5)

Thyroid peroxidase antibody Negative –

What is the most likely diagnosis?

MRCP2-1109

A 20-year-old woman presents to the endocrine clinic with complaints of irregular periods, hirsutism, and weight gain. Her GP advised her to lose weight without offering any medication. She is currently studying medicine and takes no medication from the doctor. On examination, her blood pressure is 130/80 mmHg, pulse is 70 beats per minute and regular, and her body mass index is 31 kg/m². She has extensive hirsutism affecting the beard line, upper lip, and nipples, and acne over the face and upper chest. Relevant blood tests show a testosterone level of 4.5 nmol/l (upper limit of normal 2.0 nmol/l) and an LH:FSH ratio of 2.2. Her main concern is hirsutism.

What is the most appropriate intervention for this 20-year-old woman with hirsutism, irregular periods, and weight gain?

MRCP2-1110

A 35-year-old woman with type II diabetes complains of frequent urinary tract infections (UTIs) despite multiple courses of antibiotics, including trimethoprim and amoxicillin. She reports dysuria and discomfort in her groin area. Her recent Hba1c was 100 mmol/mol (11.3%). An abdominal ultrasound showed no signs of pyelonephritis or structural abnormalities. What is the probable pathogen responsible for her UTIs?

MRCP2-1111

A 35-year-old man is being seen in clinic for follow-up. He has a history of multiple previous fractures and early onset of puberty.
During the examination, he presents with café-au-lait skin pigmentation. His pulse rate is 100 beats/min and regular, and he has sweaty palms. His thyroid function tests reveal an elevated fT4 at 23.4 pmol/l and a low TSH at 0.09 mIU/l. His bone profile (calcium, phosphate, ALP, PTH, and Vitamin D) is within normal limits.
What is the most likely diagnosis?

MRCP2-1112

A 10-year-old boy is referred to the department of paediatrics by his general practitioner. He has developed secondary sexual characteristics at the age of 8. He has no significant past medical history and does not take any regular medications. His father commenced puberty at 10 years of age.

On examination, he has a coarse voice and facial hair. His testicles have enlarged. There is acne and adult body odour. The neurological examination is unremarkable. His blood pressure was 155/88 mmHg. There is no rash.

Blood tests:

Hb 136 g/L Male: (135-180)
Female: (115 – 160)
Platelets 388 * 109/L (150 – 400)
WBC 4.2 * 109/L (4.0 – 11.0)
Na+ 138 mmol/L (135 – 145)
K+ 2.9 mmol/L (3.5 – 5.0)
Urea 4.2 mmol/L (2.0 – 7.0)
Creatinine 66 µmol/L (55 – 120)
CRP 4 mg/L (< 5)
Testosterone 42 ng/dl (7-20)
FSH 1.2 IU/L (<3)
LH 1.1 IU/L (0.02-4.8)
TSH 1.2 mIU/L (0.5-5.5)

What is the most likely diagnosis based on the given information?