Archives: MRCP Part 2

MRCP2-1656

A 78-year-old female comes to the clinic accompanied by her daughter, complaining of experiencing urinary incontinence for the past six months. She reports that she has never had any issues with continence before. Her medical history includes hypertension and angina. She now experiences urine leakage only when she laughs or coughs. Additionally, she has sudden urges to urinate throughout the day, resulting in leakage when she cannot reach the toilet in time. This has significantly affected her sleep, as it occurs more frequently at night. The patient has already reduced her caffeine intake and started bladder training as recommended by her GP. What other management strategies would you suggest?

MRCP2-1657

You are requested to assess a patient with hyperglycaemia on the ward. The patient is a 55-year-old male with type 1 diabetes mellitus. The nurse reports that his capillary blood glucose is 12.8 mmol/l. He is currently taking Humulin M3 (28 units before breakfast, and 38 units before evening meal) as per his drug history. He had his regular insulin with breakfast at 07:30.

You conduct a review at 11:30. The patient denies experiencing polyuria or polydipsia. He appears to be clinically euvolaemic. He is medically stable and is waiting for discharge from physiotherapy. You instruct the nurse to check plasma ketones, which come back at 0.4mmol/l. Upon examining his insulin chart, you observe that his blood glucose levels are typically well-managed.

What would be your approach to managing this patient?

MRCP2-1658

A 50-year-old woman is brought into the resuscitation room with a Glasgow coma scale of 11 (E2 V5 M4). A concerned family member called the emergency services, who found her in a moribund state. The family member states that she had seemed low over the past couple of months and that she had been wearing more layers of clothes than seemed appropriate.

On initial examination, she feels cool to touch. Pulse is regular and bradycardic with a heart rate of 38 beats per minute. Heart sounds 1+2 are present. Respiratory rate is 8 with oxygen saturations of 91% on 15 L. Auscultation of the chest is clear. Temperature is 33ºC. BM is 2.7.

Blood tests return as:

Hb 130 g/L Male: (135-180)
Female: (115 – 160)
Platelets 220 * 109/L (150 – 400)
WBC 9 * 109/L (4.0 – 11.0)

Calcium 2.5 mmol/L (2.1-2.6)
Thyroid stimulating hormone (TSH) 25 mU/L (0.5-5.5)
Free thyroxine (T4) 0.4 pmol/L (9.0 – 18)
Creatine kinase 6000 U/L (35 – 250)

Na+ 130 mmol/L (135 – 145)
K+ 4 mmol/L (3.5 – 5.0)
Bicarbonate 22 mmol/L (22 – 29)
Urea 8 mmol/L (2.0 – 7.0)
Creatinine 130 µmol/L (55 – 120)

What is the most appropriate management of this patient?

MRCP2-1659

A 20-year-old woman presents to the clinic with a 4-week history of increasing lethargy and weakness. She reports experiencing recurrent muscle cramps in her legs, which have been affecting her sleep. Additionally, she has been urinating up to ten times a day and feels constantly dehydrated. She also mentions that her periods, which were previously irregular, have ceased for the past 4 months.

During the examination, the patient is noted to be underweight, with a body mass index of 17kg/m². Her heart rate is 88 bpm, and her blood pressure is 108/86 mmHg.

The following laboratory results are obtained:

– C Reactive protein: 2 mg/l
– Haemoglobin: 158 g/l
– White cell count: 7.6 x 10^9/L
– Na+: 136 mmol/l
– K+: 2.9 mmol/l
– Urea: 7.2 mmol/l
– Creatinine: 108 µmol/l
– Corrected calcium: 2.42 mmol/l

A venous blood gas test reveals:

– pH: 7.532
– Bicarbonate: 37 mmol/l

What would be the most appropriate next step in investigating this patient’s condition?

MRCP2-1660

A 38-year-old female presents with 5 days of feeling generally unwell and recent dysuria. Her urine has a foul odor and is dark in color. She has a history of type 1 diabetes and has been on subcutaneous insulin for a long time. Upon admission, her pH was 7.24, bicarbonate was 8 mmol/l, and blood glucose was 32 mmol/l. Her urine dip showed 2+ leukocytes, 2+ nitrites, and 4+ ketones. She was started on treatment for diabetic ketoacidosis with intravenous fluids and fixed rate insulin, as well as intravenous antibiotics for a urinary source of sepsis. You are asked to review her blood sugars 4 hours after treatment initiation. What is the goal in managing hyperglycemia in a patient with diabetic ketoacidosis?

MRCP2-1661

A 36-year-old woman complains of fatigue, palpitations, and weight loss. As part of her diagnostic workup, thyroid function tests were conducted:

TSH <0.01mU/L 0.4-4.0mU/L
T4 15.3pmol/L 9.0-25.0pmol/L

What is the next most suitable test to perform for this patient?

MRCP2-1640

A 35-year-old woman presents to her GP with a three-month history of frequent loose stools and occasional episodes of facial flushing. She has no significant medical history, has not traveled recently, and is not taking any medications. On examination, she appears dehydrated and is referred to the hospital’s AMU.
Upon admission, blood tests reveal the following results:

Arterial pH 7.33 7.35 – 7.45
Arterial pCO2 4.5 kPa 4.7 – 6.0 kPa
Arterial pO2 13.8 kPa > 10.5 kPa
Arterial HCO3 17.8 mmol/l 22.0 – 26.0 mmol/l

Sodium (Na+) 139 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.2 mmol/l 3.5 – 5.0 mmol/l
Urea 6.8 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 91 μmol/l 50 – 120 μmol/l
Calcium (Ca2+) 2.72 mmol/l 2.2 – 2.7 mmol/l
Magnesium (Mg2+) 0.47 mmol/l 0.6 – 1.1 mmol/l
Further investigations reveal a negative stool culture for bacterial and fungal infections, and a CT scan shows a lesion on her pancreas.
What is the most likely diagnosis?

MRCP2-1641

A 32-year-old pregnant woman at 10 weeks gestation seeks advice on how to rule out gestational diabetes. She has a BMI of 28.7 and a family history of type 1 diabetes in her cousin and breast cancer in her aunt. She has had two previous pregnancies, one of which ended in miscarriage at 8 weeks and the other resulted in a healthy baby with a birth weight of 4.6kg. What testing regimen would be most appropriate for ruling out gestational diabetes in this patient?

MRCP2-1642

A 50 year-old woman presents with a two day history of nausea and fever. On admission she is confused and her husband states that she was recovering from a recent upper respiratory tract infection and sore throat. He also mentions she has previously been experiencing episodes of diarrhoea and palpitations over the last three months.

Examination reveals a temperature of 40.6ºC, pulse rate of 160 beats per minute and blood pressure of 110/70 mmHg. Her pulse is irregularly irregular. Heart sounds 1 and 2 are present with no added sounds, lung fields are clear and her abdomen is soft and nontender, with bowel sounds being present.

Blood tests are taken and reveal:

Hb 13.2 g/dL
Platelets 180 * 109/l
WBC 10.2 * 109/l
Na+ 135 mmol/l
K+ 4.2 mmol/l
Urea 7.2 mmol/l
Creatinine 132 µmol/l
Thyroid stimulating hormone (TSH) 0.03 mu/l
Free thyroxine (T4) 31 pmol/l
Total thyroxine (T4) 220 nmol/l

What is the most appropriate immediate treatment?

MRCP2-1643

A 20-year-old woman presents to the endocrinology clinic with a history of feeling weak and needing a sweet drink to improve. This has been happening frequently since she was rejected from applications to medical school. She has a previous history of anxiety, but her parents have become concerned after using her sister’s glucose monitoring equipment (who has type 1 diabetes) and finding her capillary glucose as low as 2 mmol/l. They are worried that she may have an insulinoma after reading about it on the internet and have requested an endocrinology referral from the GP. What is the most appropriate investigation to rule out insulinoma?