Archives: MRCP Part 2

MRCP2-1552

A 35 year old man presents to the Emergency Department with tiredness and dizziness (worse on standing) which has been ongoing for the past few months. He had a past medical history of epilepsy and mentions that he has had ‘brain surgery’ in the past. He is on some medications but cannot remember the names. He has no allergies.

On assessment, he has no focal neurological deficit and cardiovascular/respiratory examination is normal. Observations show a blood pressure of 135/90 mmHg (dropping to 105/82 mmHg on standing), a heart rate of 67 beats per minute, a temperature of 36.2 degrees, oxygen saturations of 94% on air and a respiratory rate of 18/min. Given his medical history, you opt to keep this gentleman in the short stay unit for observation overnight.

Baseline blood tests are as follows:

Hb 125 g/l
WCC 9.2 x109/l
Plt 290 x109/l
CRP 10 mg/l
Gluc 3.9 mmol/l
Na+ 138 mmol/l
K+ 5.8 mmol/l
Ur 7.2 mmol/l
Cr 100 µmol/l
TSH 0.4 mU/l
T4 5.0 pmol/l

What is the most likely underlying diagnosis based on the given information?

MRCP2-1553

A 51 year old man presents to his GP for a routine check-up. He has a medical history of hypertension which has been managed with ramipril for the past 3 years. During the check-up, the GP notes that the patient has been experiencing low back pain for the past few weeks, which has been relieved with over-the-counter paracetamol and ibuprofen. The patient’s blood pressure is 136/78 mmHg. As part of the check-up, blood tests are ordered and the results are as follows:

Hb: 13.5 g/dl
Platelets: 320 * 109/l
WBC: 8.0 * 109/l

Na+: 140 mmol/l
K+: 6.8 mmol/l
Urea: 6.0 mmol/l
Creatinine: 118 µmol/l

Upon seeing these results, the GP immediately refers the patient to the local Medical Assessment Unit for further testing. The following tests are carried out:

Arterial Blood Gases:
pH: 7.35
PaCO2: 5.0 kPa
PaO2: 11.8 kPa
HCO3-: 20 mmol/l

Serum Chloride: 122 mmol/l

Urinalysis:
pH: 4.9
Protein: negative
Blood: negative
Leukocytes: negative
Glucose: negative

What is the most likely diagnosis?

MRCP2-1554

A 42-year-old woman presents with a recent history of weight loss and anxiety. She had been diagnosed with thyrotoxicosis three years ago and had been treated with carbimazole, but failed to attend follow-up appointments for over a year. Although she felt better after the treatment, she still had a goitre. Recently, she noticed a more prominent swelling on the right side of her neck and experienced symptoms of anxiety, along with a 3 kg weight loss. She is currently not taking any medication but is a smoker of 10 cigarettes daily.

During the examination, the patient had a pulse of 96 beats per minute, a fine tremor of the outstretched hands, lid lag, and some periorbital puffiness. There was a moderately enlarged and diffuse goitre with a more prominent 3 cm nodule on the left of the gland, which was non-tender. A bruit was heard over the goitre, and no lymphadenopathy was palpable. No other abnormalities were noted.

The investigations revealed a free T4 level of 37.3 pmol/L (10-22), a TSH level of 0.05 mU/L (0.4-5), and thyroid peroxidase antibodies of 1:2400 U/L. The I123 uptake scan showed diffuse uptake with no uptake in the left nodule. What is the most likely cause of the thyroid nodule?

MRCP2-1521

A 35-year-old woman presents to the endocrinology clinic with a 3-week history of intermittent headaches and milky discharge from her nipples. She also reports missing her menstrual periods for the past 6 months despite having a regular 28-day cycle. The patient has no significant medical history and no known allergies.

Lab results:

– Thyroid-stimulating hormone (TSH): 0.6 mU/L (0.5-5.5)
– Free thyroxine (T4): 8.2 pmol/L (9.0-18.0)
– Adrenocorticotrophic hormone: 8 ng/L (0-47)
– Insulin-like growth factor 1 (IGF-1): 11 nmol/L (12.4-30.3)
– Prolactin: 5500 IU/mL (59-619)
– β-HCG: <1 u/L (<1) An MRI of the head reveals a pituitary adenoma measuring approximately 1.5cm, which is compressing the optic chiasm. What is the most appropriate next step in managing this patient’s likely diagnosis?

MRCP2-1522

A 32-year-old woman with a history of epilepsy visits her primary care physician for a check-up. She has recently started taking carbamazepine after experiencing more frequent seizures. Over the past week, she has been experiencing worsening fatigue, headaches, and occasional confusion, as reported by her partner. What is the most likely diagnosis based on these symptoms?

MRCP2-1523

A 28-year-old nulligravida woman presents to her GP with a complaint of not having menstruation for 6 months. She had irregular periods from age 14-16 and then took oral hormonal contraception until last year when she got married. The patient is adopted and does not know her family history. She is physically fit, enjoys recreational running, and maintains a healthy diet. She does not smoke, drink, or use illicit drugs. Her vital signs are normal, and her body mass index is 22 kg/m².

On physical examination, no abnormalities are found, and a urine pregnancy test is negative. What is the most appropriate screening test for this patient?

MRCP2-1524

A 63-year-old man presents to the Emergency department with persistent nausea and vomiting for the past 3-4 weeks. He has a history of Type 2 diabetes for the past 8 years and is currently on a medication regimen of metformin, sitagliptin, and empagliflozin. He reports a recent weight loss of approximately 6kg. On examination, his blood pressure is 112/68 mmHg, his pulse is regular at 86 beats per minute. Laboratory results show elevated ketones and a glucose level of 12.5 mmol/l.

What is the most appropriate approach to managing his glucose control?

MRCP2-1525

A 32-year-old man is referred to the clinic by his primary care physician, having been experiencing fatigue and dizziness for several weeks. On examination, his BP is 110/70 mmHg, pulse is 80/min. His BMI is 22. He has calluses on his knuckles, but tells you these are due to his job as a mechanic.

Investigations:

Haemoglobin 120 g/l 130–170 g/l
White cell count (WCC) 6.0 × 109/l 4–11 × 109/l
Platelets 200 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 3.2 mmol/l 3.5–5.0 mmol/l
Creatinine 100 µmol/l 50–120 µmol/l
Urinary K+ 0.5 mmol/l/24 h 25–100 mmol/24 h

What is the most likely diagnosis for this patient?

MRCP2-1526

A 70-year-old patient was referred to the emergency department after being found unresponsive in her home. She had a history of chronic obstructive pulmonary disease and had been on antibiotics for a chest infection. She had not been seen for the preceding 24 hours. She had a past medical history of hypertension and hyperlipidemia.

Her medication included Salbutamol, Ipratropium, Prednisolone, Atorvastatin, and Amlodipine.

Her initial examination revealed a blood pressure of 110/60 mmHg, heart rate of 95 beats per minute, respiratory rate of 22, and oxygen saturation of 92% on air. She had wheezing on both lung fields. She had sunken eyes, capillary refill time of three seconds, and no lower limb swelling. Her Glasgow coma scale was 14 out of 15.

Initial blood tests showed:

Hb 12.5 g/dL
WCC 18.2 *10^9/l
Platelets 210 *10^9/l
CRP 280 mg/L
Na+ 148 mmol/l
K+ 4.2 mmol/l
Ur 25 mmol/l
Cr 150 µmol/l
Glucose 8 mmol/l

ABG on air:

pH 7.35
pCO2 4.5 kPa
pO2 8.5 kPa
HCO3 22 mmol/l
Lactate 1.8 mmol/l

Urine dipstick analysis – ++ glucose, – WCC, – leucocytes, + ketones

The patient was treated with oxygen, intravenous antibiotics for a chest infection, and nebulized bronchodilators. They were also treated with intravenous fluids and insulin sliding scale as per the local diabetic ketoacidosis protocol.

Her repeat bloods 12 hours later were:

Na+ 135 mmol/l
K+ 4.0 mmol/l
Ur 15 mmol/l
Cr 130 µmol/l
Glucose 6 mmol/l
HCO3 24 mmol/l
Lactate 1.5 mmol/l
CRP 250 mg/l

The patient developed a sudden onset of confusion and agitation. Her Glasgow coma scale decreased to 8 an hour after the onset of symptoms.

What is the most likely cause of her neurological

MRCP2-1527

A 35-year-old female patient visits her GP complaining of frequent headaches, excessive sweating, reduced peripheral vision, deepening of her voice, and absence of menstrual periods. She has also noticed an enlargement of her lower jaw. Upon examination, mild hirsutism is observed. Visual tests reveal bitemporal hemianopia. Diagnostic tests show a fasting blood glucose level of 7.8 mmol/l and a 2-hour post-prandial value of 12.5 mmol/l. Prolactin levels are elevated at 1000. Her BP is high at 165/99 mmHg. An MRI scan shows a 20 mm pituitary adenoma. What would be the most appropriate initial management for this case?