Archives: MRCP Part 2

MRCP2-1593

An 80-year-old man comes to the endocrine clinic for evaluation. He has been taking amiodarone for the past few months for short episodes of VT diagnosed after a heart attack. Over the last 2 months, he has experienced weight loss and heat intolerance, along with short runs of an irregular, fast heartbeat. During the clinic visit, his BP is 112/82, pulse is 88 and regular, and his BMI is 21. Thyroid function testing reveals an abnormality, with a suppressed thyroid-stimulating hormone (TSH) suggestive of thyrotoxicosis. Radioiodine uptake scan is normal, as is serum interleukin 6 (IL-6). A recent ECHO cardiogram showed an ejection fraction of 38%.
After a repeat ECHO cardiogram and a 72 h tape, which shows paroxysmal AF but no episodes of VT, the cardiologist discontinues his amiodarone. What is the best initial therapy for this patient?

MRCP2-1594

A 63-year-old woman presents to the diabetes nephropathy clinic for follow-up. She has a history of chronically elevated creatinine and microalbuminuria. Her current medications include basal bolus insulin, ramipril 10 mg, amlodipine 5 mg, and bisoprolol 10 mg. On examination, her blood pressure is 155/72 mmHg, pulse is 72 and regular, and she has neuropathy to the mid shin.

Further investigations reveal a haemoglobin level of 110 g/L (115 – 160), white cell count of 8.8 ×109/L (4 – 11), platelets of 199 ×109/L (150 – 400), sodium of 138 mmol/L (135 – 146), potassium of 5.2 mmol/L (3.5 – 5), and creatinine of 299 µmol/L (240 one year earlier) (79 – 118).

What is the appropriate management of her blood pressure?

MRCP2-1595

A 50-year-old man with a 22 year history of type 1 diabetes presents at the clinic for a check-up. His recent HbA1c reading was 66 mmol/mol. He reports experiencing regurgitation of food, indigestion, and difficulty determining the correct dose of meal time insulin. During the examination, his blood pressure is measured at 135/90 mmHg with a postural drop of 20 mmHg. Additionally, he displays bilateral sensory loss to the mid shin on both legs. What is the most appropriate initial treatment for this patient?

MRCP2-1596

A 60-year-old man with type II diabetes mellitus presents to the Diabetic Clinic for follow-up. He has been diabetic for 8 years, diet controlled for 3 years and on gliclazide and metformin since then. However, he has missed several follow-up appointments. On examination, his blood pressure is 126/78 mmHg and there is no evidence of peripheral neuropathy. Previous investigations showed a HbA1c of 44.82 mmol/mol (6.2%), negative protein and glucose, and normal electrolyte and renal function. A 24-hour urine collection revealed 200 mg of albumin. What is the most effective management strategy to improve his overall prognosis for renal and other complications?

MRCP2-1597

A 30-year-old female comes in for her annual check-up. She was diagnosed with diabetes mellitus at age 16 and is currently being treated with human mixed insulin twice daily. She has been experiencing dysuria for the past year and has received treatment with trimethoprim four times for cystitis. On examination, two dot haemorrhages are seen bilaterally on fundal examination, but her blood pressure is normal at 116/76 mmHg. Her test results show elevated HbA1c levels, fasting plasma glucose, and glucose in her urine, but her serum sodium, potassium, urea, and creatinine levels are within normal range. Her 24-hour urine protein level is slightly elevated. What is the best course of treatment to prevent the progression of renal disease?

MRCP2-1598

A 28-year-old woman is referred to the Pregnancy Diabetes Clinic after two weeks of diet and exercise failed. Her first child was born at a normal size. She is currently 20 weeks pregnant and has no significant medical history. The following investigations were conducted:

Investigation Result
Fasting plasma glucose 6.9 mmol/l
Oral glucose tolerance test at 2 hours 11.4 mmol/l

What is the next best course of action in this scenario?

MRCP2-1599

A 55-year-old woman with Graves’ disease presents for a check-up on her thyroid status. She is on propranolol and carbimazole. During the visit, she reports experiencing eye pain and double vision, especially when looking to the sides. Upon examination, there is significant proptosis. Her blood pressure is 122/82, pulse is regular at 60. Despite using artificial tears and eye patches, she has not found relief. What is the first-line treatment to improve her ophthalmopathy?

MRCP2-1600

A 63-year-old man with a history of type 2 diabetes presents at the clinic for a check-up. He is currently being treated with BD mixed insulin and metformin to prevent weight gain associated with insulin use. The patient has a medical history of an inferior myocardial infarction and severe narrow-angle glaucoma. Recently, he has been experiencing severe burning pain in both of his lower legs.

During the examination, the patient’s blood pressure is 142/82 mmHg, pulse is 70 and regular. He has lost sensation below the knees in both legs. The following investigations were conducted:

– Haemoglobin: 127 g/L (135-177)
– White cell count: 6.9 ×109/L (4-11)
– Platelets: 189 ×109/L (150-400)
– Sodium: 138 mmol/L (135-146)
– Potassium: 4.9 mmol/L (3.5-5)
– Creatinine: 143 µmol/L (79-118)
– HbA1c: 63 mmol/mol (<48) or 7.9% (<6.5) According to NICE guidance, what is the most appropriate way to manage his neuropathic pain?

MRCP2-1590

A 16-year-old male is admitted to the Emergency department with pneumonia. He has classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency and is currently taking prednisolone 7.5 mg daily and fludrocortisone 100 mcg/day. On examination, he has a temperature of 38.2°C, BP of 90/65 mmHg, pulse of 95 and regular, and signs of left lower lobe pneumonia. Investigations reveal abnormal levels of haemoglobin, white cell count, platelets, sodium, potassium, and creatinine. What would be your recommendation regarding the management of his steroid therapy?

MRCP2-1591

A 65-year-old man with type 2 diabetes mellitus (insulin controlled) and end-stage renal failure (haemodialysis dependent for five years) was admitted to the coronary care unit six hours ago, with an acute inferior myocardial infarction.

Despite appropriate therapy, including thrombolysis, he continues to have ischaemic symptoms, and is in pulmonary oedema. His last haemodialysis session was 48 hours prior to admission. His blood pressure is 86/52 mmHg.

Investigations show:

– Serum sodium 139 mmol/L (137-144)
– Serum potassium 6.7 mmol/L (3.5-4.9)
– Serum urea 49 mmol/L (2.5-7.5)
– Serum creatinine 950 µmol/L (60-110)
– Haemoglobin 108 g/L (130-180)
– Troponin T >25 g/L (<0.04) A transthoracic echocardiogram shows a left ventricular ejection fraction of 20%. What is the most appropriate management strategy?