MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1063

A 30-year-old woman presents to the emergency department with complaints of feeling unwell and experiencing shortness of breath. She has a medical history of type 1 diabetes mellitus and is known to be non-compliant with insulin therapy.

Upon examination, her vital signs are as follows: heart rate of 89 beats per minute, blood pressure of 111/77 mmHg, oxygen saturation of 96% on room air, respiratory rate of 24/minute, and a temperature of 37C.

A VBG reveals a pH of 7.05 (normal range: 7.35-7.45), lactate of 2.8 mmol/L (normal range: 0.0-2.0), HCO3- of 8 mmol/L (normal range: 22-26), K+ of 4.2 mmol/L (normal range: 3.5-5.5), Na+ of 128 mmol/L (normal range: 135-145), and glucose of 31 mmol/L (normal range: 4.0-7.8). Ketones are also present at 4.2 mmol/L (normal range: <0.6). The patient is started on IV fluids (IV 0.9% sodium chloride with added potassium) and a fixed rate insulin infusion. Four hours later, repeat investigations show improvement with a pH of 7.12, lactate of 2.2 mmol/L, HCO3- of 12 mmol/L, K+ of 4.6 mmol/L, Na+ of 131 mmol/L, glucose of 10 mmol/L, and blood ketones of 3.2 mmol/L. Based on the likely diagnosis, what is the most appropriate management choice at this point?

MRCP2-1064

A 76-year-old man with metastatic lung carcinoma presents with increasing lethargy and a number of falls. He describes feeling very unsteady on standing from his bed. His appetite has been poor and he has vomited two times each day for the past three days. There is no diarrhoea or abdominal pain and he denies any shortness of breath. He takes regular paracetamol for pain and omeprazole for dyspepsia.

On examination, he is a tanned gentleman with cachexia. He appears pale with dry mucosa and his abdomen is soft and non-tender. There is reduced air entry at the right base with bronchial breathing overlying. His heart sounds are normal and his capillary refill time is prolonged to 4 seconds. Bloods pressure is 85/65 mmHg, heart rate 86/min, respiratory rate 23/min

Hb 102 g/l Na+ 129 mmol/l
Platelets 189 * 109/l K+ 5.0 mmol/l
WBC 5.6* 109/l Urea 7.2 mmol/l
Neuts 4.2 * 109/l Creatinine 87 µmol/l
Lymphs 0.7 * 109/l CRP 32 mg/l
Eosin 0.1 * 109/l

CT-chest-abdomen-pelvis There is a 4cm mass in the right lower lobe with extension to adjacent pleura. Bilateral pleural effusions are present. There is mediastinal lymphadenopathy and enlargement of para-aortic nodes with masses seen in both adrenals. Findings are in keeping with a primary lung malignancy with metastatic spread

What is the most probable cause of this presentation?

MRCP2-1049

A 35-year-old woman comes to the clinic with concerns about her sexual health. She reports experiencing vaginal dryness during intercourse and has noticed that her breasts leak milk with minimal stimulation. She also mentions that she has not had a period in the past 6 months. Her medical history includes recent use of metoclopramide for nausea. On examination, her blood pressure is 140/80 mmHg, pulse is 80/min and regular. She has some peripheral field visual loss. Laboratory results show elevated prolactin levels and abnormal thyroid function tests. Which of the following is the most likely diagnosis?

MRCP2-1065

A 14-year-old boy is brought to the Emergency department by his parents. He has a two day history of general malaise, vomiting and vague abdominal discomfort. Over the past twelve hours he has become increasingly drowsy.

On examination, he was unresponsive to verbal commands. His temperature was 36.5°C and his blood pressure was 74/48 mmHg. The following investigations were done:

– Sodium: 121 mmol/L (137-144)
– Potassium: 6.2 mmol/L (3.5-4.9)
– Urea: 11.6 mmol/L (2.5-7.5)
– Creatinine: 162 µmol/L (60-110)
– Glucose: 1.1 mmol/L (3.0-6.0)
– Chloride: 91 mmol/L (95-107)
– Bicarbonate: 14 mmol/L (20-28)

After giving emergency treatment, what single investigation would be most valuable in confirming the diagnosis?

MRCP2-1050

A 56-year-old man presented to endocrine clinic with gradually worsening low mood, malaise, and reduced exercise capacity. He had a history of non-functioning pituitary adenoma (NFPA) surgery resulting in partial anterior hypopituitarism and was on thyroxine and hydrocortisone replacement therapy. He had central adiposity and a medical history of dyslipidaemia, epilepsy, and ischaemic heart disease (IHD). Due to his medical history, an insulin tolerance test was contraindicated.

The following investigations were conducted: 9am cortisol 415 nmol/l, IGF-1 8 nmol/l (16 – 118), FT4 15.4nmol/l (11.5 – 22.7), and TSH 0.03mU/l (0.35 – 5.5).

What is the most appropriate test to confirm the diagnosis of adult GH deficiency in this case?

MRCP2-1066

A 25-year-old female presents with acute illness. She has been experiencing weight loss, tiredness, and lethargy for the past three months, which has worsened over the last week. Her general practitioner had diagnosed her with hypothyroidism six weeks ago, with a Free T4 level of 8.8 pmol/L (10-22) and a Plasma TSH level of 5.5 mU/L (0.4-5). She had started taking thyroxine 50 µg daily but has deteriorated over the last two weeks. Her mother and maternal grandmother have also been diagnosed with hypothyroidism and take thyroxine. She is a non-smoker, does not drink alcohol, and takes the oral contraceptive pill.

On examination, she appears unwell and mildly dehydrated, with a temperature of 37.5°C and a BMI of 21.3 kg/m2. Her blood pressure is 72/44 mmHg, with a pulse of 100 beats per minute. Cardiovascular examination is otherwise normal, and there are no abnormalities on respiratory or abdominal examination. Brief neurological examination is normal, and both plantars are flexor.

The investigations requested by the house officer are currently unavailable. In the meantime, what is the most appropriate immediate management for this patient?

MRCP2-1051

A 32-year-old woman comes to the clinic with a complaint of a lump at the base of her neck. She has noticed that it has become more noticeable when she swallows and has grown significantly over the past 8 weeks. She also reports experiencing diarrhea for the past few months. During the clinical examination, a thyroid nodule is discovered. Further questioning reveals that her aunt had a thyroidectomy due to cancer. The following investigations were conducted:

s
Haemoglobin (Hb) 130 g/l 135 – 175 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+) 142 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 100 μmol/l 50 – 120 μmol/l
Corrected calcium (Ca2+) 2.75 mmol/l 2.2 – 2.7 mmol/l
Ret oncogene positive

What is the most likely diagnosis in this case?

MRCP2-1067

A 35-year-old man presents to the Emergency Department two weeks after being discharged following surgery for a ruptured appendix. He experienced significant blood loss during the procedure and required a blood transfusion. He has been feeling increasingly fatigued with episodes of dizziness and near-fainting. On examination, he appears pale and his blood pressure is 100/70 mmHg with a 15 mmHg drop on standing. His pulse is 90 bpm and regular. His BMI is 25 kg/m2.

Investigations:
Haemoglobin (Hb): 105 g/l (normal range: 130-170 g/l)
White cell count (WCC): 7.5 × 109/l (normal range: 4-11 × 109/l)
Platelets (PLT): 180 × 109/l (normal range: 150-400 × 109/l)
Sodium (Na+): 132 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+): 5.2 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Cr): 100 µmol/l (normal range: 50-120 µmol/l)

What is the underlying pathology causing this patient’s symptoms?

MRCP2-1052

A 28-year-old woman presents to her general practitioner with complaints of fatigue. She is 28 weeks pregnant with her first child. She has no past medical history and is not taking any medications.

Upon examination, her abdomen is distended with a symphysis-fundal height that is consistent with gestational age. Foetal movements are observed.

The following blood tests were conducted:

– Hb 138 g/L (Male: 135-180, Female: 115-160)
– Platelets 189 * 109/L (150-400)
– WBC 4.2 * 109/L (4.0-11.0)
– Na+ 138 mmol/L (135-145)
– K+ 4.2 mmol/L (3.5-5.0)
– Urea 5.2 mmol/L (2.0-7.0)
– Creatinine 88 µmol/L (55-120)
– CRP 4 mg/L (<5)
– Bilirubin 12 µmol/L (3-17)
– ALP 145 u/L (30-100)
– ALT 32 u/L (3-40)
– Albumin 36 g/L (35-50)

What is the most probable cause of her symptoms?

MRCP2-1053

A 42-year-old woman with Graves’ disease is referred by her GP for management of thyroid eye disease. She has a history of drinking 10 units of alcohol per week and smoking 20 cigarettes per day. On examination, she has a smooth goitre, marked proptosis, a fine tremor, and a blood pressure of 112/88 mmHg with a pulse of 89 beats per minute. What factor has the most significant negative impact on her thyroid eye disease prognosis?