Archives: MRCP Part 2

MRCP2-1639

A 65-year-old lady presents for a follow-up appointment. She had presented 6 months previously under the acute medical take with headaches, sweating, abdominal pain and wild fluctuations in blood pressure. She is currently being followed up by the appropriate surgical team and her symptoms are currently well controlled with medical treatments. On examination today, you note a lump in her anterior neck and you are given the following blood tests:

Calcium (corrected) 3.68 mmol/l
Phosphate 0.38 mmol/l
Vitamin D3 115 nmol/l (75-200 nmol/l)
Parathyroid hormone 19 pmol/l (0.8 – 8.5 pmol/l)

You have referred the patient to endocrine surgeons for neck biopsies and urgent review. Her daughter, who came with her to the consultation, is worried about her own risk of developing similar symptoms in the future. What advice can you offer the daughter?

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?

MRCP2-1644

A 65-year-old man presents for a routine medical check-up at his GP clinic. He has a history of childhood asthma and osteoarthritis in his fingers but is otherwise healthy. During the check-up, his vital signs were recorded as a blood pressure of 129/80 mmHg, pulse rate of 82 bpm, and oxygen saturation of 97%. Blood tests were ordered and the results showed normal levels for most parameters, except for a slightly elevated γGT and serum corrected calcium. A 24-hour urinary calcium test was performed, which revealed a significantly low result. Based on these findings, what is the most likely diagnosis?

MRCP2-1620

A 67-year-old lifelong smoker presents with a 3-week history of gradually worsening confusion, abdominal discomfort and constipation. He admits to a chronic cough which has worsened over the past nine to twelve months, and that he has lost 7 kg in weight.
On examination, his blood pressure (BP) is 148/80, with pulse 76 and regular. There is bilateral wheeze on auscultation of the chest consistent with COPD. He looks thin, with a BMI of 20.
Investigations:
s
Sodium (Na+) 137 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 110 µmol/l 50 – 120 µmol/l
Urea 7.5 mmol/l 2.5 – 6.5 mmol/l
Corrected calcium (Ca2+) 3.02 mmol/l 2.2 – 2.7 mmol/l
Albumin 30 g/l 35 – 55 g/l
Alkaline phosphatase (ALP) 155 u/l 30 – 150 u/l
Parathyroid hormone (PTH) 0.7 pmol/l 0.9 – 5.4 pmol/l
What is the most likely cause of his hypercalcaemia?

MRCP2-1621

A frail 83-year-old gentleman was brought in by his son, who found him on the floor in his apartment. He had tripped in a mechanical and had been unable to get back up, lying on the floor for the past 3 days. On examination, he appears extremely dehydrated but has no specific focal weakness, systemic examination is unremarkable. He has sustained no musculoskeletal injuries. His blood tests are as follows:

Na+ 168 mmol/l
K+ 6.0 mmol/l
Urea 24 mmol/l
Creatinine 260 µmol/l (baseline 107 three months ago)
Creatinine kinase 11,000 mmol/l

ECG shows normal sinus rhythm at 99/ minute.

You diagnose him with rhabdomyolysis and an acute kidney injury, likely of a pre-renal cause. Intravenous fluid rehydration is initiated with intravenous 5% dextrose. You ask your colleague to check the patient’s blood tests in 12 hours.

What is the reason for correcting the patient’s hypernatraemia?

MRCP2-1622

A 35-year-old construction worker presents for review. He is 6 feet 2 inches tall and has signs of delayed puberty and infertility on examination, notably small testes with scanty pubic hair.
Investigations:
s
Follicle-stimulating hormone (FSH) 40 u/l 1 – 7 u/l
Testosterone 6 nmol/l 9 – 25 nmol/l
What is the most likely diagnosis based on this clinical presentation and laboratory results?

MRCP2-1623

A 38-year-old woman presents to the emergency department with a suspected drug overdose and reduced GCS. She has a history of type 2 diabetes and takes gliclazide. Upon examination, she appears pale and sweaty. During her initial assessment, the following result is obtained:

Blood glucose 2.0 mmol/L (>3.9 mmol/L)

After receiving an infusion of 50% dextrose, her glucose level is rechecked:

Blood glucose 2.5 mmol/L (>3.9 mmol/L)

What other treatment options should be considered to stop the underlying process?