MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine
MRCP2-1577
A 65-year-old type II diabetic woman presents to the Diabetic Clinic as a new patient referred from her General Practitioner (GP). She has a past history of hyperlipidemia, osteoporosis and hypothyroidism.
On examination, her body mass index (BMI) is 32 kg/m2. She is currently on metformin 1000 mg twice a day and has excellent compliance. She was previously on glimepiride in addition to metformin, but this was stopped when she experienced severe hypoglycemia. Her HbA1c is 75.18 mmol/mol (9%).
Which one of the following treatments would be the most appropriate?
MRCP2-1578
A 57-year-old man with a medical history of type 2 diabetes mellitus, gout, obesity, and cholecystectomy presents to the clinic. He takes metformin and allopurinol and has no known allergies. His total cholesterol level is 4.8 mmol/mol. The patient is concerned about his risk of heart attack after his brother recently suffered one. He smokes five cigarettes per day and is trying to reduce his intake. His blood pressure is 132/71 mmHg. What is the best course of action?
MRCP2-1579
A 35-year-old patient is being discharged from the hospital after his third admission for DKA in the past two years since being diagnosed with type 1 diabetes mellitus. The patient has stopped his fixed-rate IV insulin and has resumed eating and drinking. He has restarted his long-acting insulin detemir (Levemir) and short-acting insulin aspart (Novorapid) as per his pre-admission plan. The patient’s DKA was most likely triggered by his alcohol consumption and failure to take his insulin, which is similar to his previous admissions. Although he only drinks two bottles of beer per week, he occasionally binge drinks. The patient has no other medical conditions and takes no other medications. What is the best recommendation to prevent future DKA admissions?
MRCP2-1580
A 46-year-old woman arrives at the emergency department complaining of weight loss, nausea, and feeling excessively hot. She has a history of cardiomyopathy and has an ICD implanted. Due to recurrent episodes of ventricular tachycardia, she takes amiodarone. Her blood tests reveal an undetectable thyroid stimulating hormone, and she also has rheumatoid arthritis. A previous angiogram showed no signs of coronary artery disease. She is currently taking methotrexate, aspirin, paracetamol, omeprazole, warfarin, and bisoprolol. The suspected diagnosis is acute thyrotoxicosis. What is the most appropriate course of action regarding her medication, in addition to discontinuing amiodarone?
MRCP2-1581
A 23-year-old woman is distressed by her five-year history of hirsutism, particularly the coarse dark hair under her chin. As a primary school teacher, this is affecting her confidence. She has tried shaving and depilatory creams without lasting success. Her periods are irregular with oligomenorrhoea, and she has not yet conceived. During the follicular phase, investigations showed elevated levels of androstenedione, dehydroepiandrosterone sulphate, and 17-hydroxyprogesterone, as well as slightly elevated prolactin levels. What is the most appropriate treatment for her hirsutism and underlying condition?
MRCP2-1582
A 29-year-old female presents with recurrent vulval candidiasis.
She has gained approximately 20 kg in weight since the birth of her last child four years ago. During this pregnancy she recalls that she received insulin for approximately four months although this was discontinued after the birth of her daughter who is quite well. She also has two older children who are well although she did not receive insulin during those pregnancies.
She is a smoker of 12 cigarettes per day and drinks approximately 12 units of alcohol weekly.
There is a strong family history of coronary artery disease; her father and paternal uncle both died in their fifties of heart disease. Her mother has diabetes and takes thyroxine for a thyroid problem.
On examination she weighs 90 kg with a body mass index of 36.5 kg/m2. Her pulse is regular, 82 beats/minute and her blood pressure is 140/88 mmHg. Otherwise examination of the heart, chest and abdomen is unremarkable.
Fundal examination reveals three dot haemorrhages in the left and two dot haemorrhages in the right retina. There are no abnormalities of sensation in the feet or hands. Peripheral pulses are all normal.
Investigations reveal:
HbA1c 66 mmol/mol (20-46)
8.2% (3.8-6.4)
Fasting plasma glucose 10.3 mmol/L (3.0-6.0)
Serum urea 5.1 mmol/L (2.5-7.5)
Serum creatinine 108 µmol/L (60-110)
Serum alkaline phosphatase 100 U/L (45-105)
Serum HDL cholesterol 0.8 mmol/L (>1.55)
Serum total cholesterol 7.2 mmol/L (<5.2)
Fasting serum triglyceride 2.8 mmol/L (0.45-1.69)
What treatment should be given to this patient, in addition to lifestyle advice?
MRCP2-1583
A 38-year-old Spanish man presents to his doctor with increasing fatigue. He had visited the clinic twice in the past few months and was prescribed antidepressants during his last visit. Recently, he had been experiencing more frequent episodes of nausea and vomiting and had lost a significant amount of weight.
During the examination, his blood pressure was 110/70 mmHg and his BMI was 22. There was a postural drop of 15 mmHg in his blood pressure upon standing, along with an increase in his pulse rate.
What is the initial treatment of choice for this patient?
MRCP2-1584
You are asked to interpret the results of a synacthen test on the Geriatrics Ward. The patient is a 65-year-old man who is in hospital for treatment of pneumonia. He has been experiencing difficulty breathing and has a persistent cough.On examination, pulse 100/min regular, BP 110/70 mmHg. His JVP is not seen, his heart sounds are normal and his chest is dull to percussion. Abdominal and neurological examination is normal.Short synacthen test:Time (min) 0 30 60 cortisol (nmol/l) 80 120 135. Given the likely diagnosis, what is the most crucial aspect of your immediate management?
MRCP2-1585
A 55-year-old woman with type II diabetes and chronic renal failure on haemodialysis presents with unstable angina. She is currently using twice daily insulin for glycaemic control, but her control has been poor recently.
What is the most appropriate treatment for this patient?
MRCP2-1586
A 54-year-old woman presents with a six-month history of weight loss, loose stools, and hot flashes. She went through menopause five years ago without any issues, but her symptoms have worsened over the past six months. She experiences diarrhea four times a day, intermittent hot flashes, and has lost approximately 6 kg in weight during this time. She has type 2 diabetes, which she manages with diet alone, and takes no other medications. She does not smoke and drinks about 10 units of alcohol per week. On examination, she has a BMI of 28.1 kg/m2, a pulse of 80 bpm, and a blood pressure of 128/78 mmHg. Auscultation of the chest reveals a few scattered expiratory wheezes, and examination of the abdomen reveals 4 cm hepatomegaly.
Investigations reveal normal full blood count and urea and electrolytes. Her plasma glucose is 8.8 mmol/L (3.0-6.0), and her HbA1c is 62 mmol/mol (20-46) or 7.8% (3.8-6.4). Her AST, ALT, and Gamma GT are within normal ranges, but her alkaline phosphatase is elevated at 128 U/L (60-110). Her oestradiol is low at 63 pmol/L (120-800), while her LH and FSH are high at 55 U/L (>40) and 88 U/L (>50), respectively. Her free T4 is normal at 15.8 pmol/L (10-22), and her TSH is 2.2 mU/L (0.4-5). Her urine analysis shows glucose+ and an elevated urine hydroxyindoleacetic acid (HIAA) level of 148 µmol/24hr (10-50).
What is the most appropriate treatment for this patient?