Archives: MRCP Part 2

MRCP2-1500

A 26-year-old woman presents to the emergency department after being found unwell by friends. She has a history of vomiting and diarrhea for the past three days and her housemate reports that she has not been taking her regular insulin. The patient is disorientated and unable to provide any history. On examination, she is dehydrated with abdominal tenderness but no focal peritonism. Her vital signs show a blood pressure of 86/57 mmHg, heart rate of 127 beats per minute, respiratory rate of 28 per minute, and O2 saturations of 100% on room air. Her fingerpick blood glucose is 38.2 mmol/L and blood ketones are 8.7 mmol/L. Arterial blood gas shows a pH of 7.05, PaCO2 of 15 mmHg, PaO2 of 99 mmHg, bicarbonate of 12.3 mmol/L, chloride of 111 mmol/L, and lactate of 7.5 mmol/L. What is the appropriate strategy for intravenous insulin treatment in this patient?

MRCP2-1475

A 23-year-old woman with a history of type 1 diabetes presents to the Emergency department. She has been experiencing a viral upper respiratory tract infection that has worsened over the past three days, and her latest BM estimation shows her glucose has risen to 33 mmol/L. On examination, she has a fever of 37.9°C, a BP of 100/60 mmHg, and a pulse of 95. She has signs of pharyngitis and a cough, and her respiratory rate is elevated at 30.

Investigations reveal a haemoglobin level of 119 g/L, a white cell count of 10.2 ×109/L, platelets of 220 ×109/L, sodium of 139 mmol/L, potassium of 4.5 mmol/L, creatinine of 132 µmol/L, bicarbonate of 14 mmol/L, pH of 7.15, and glucose of 38.1 mmol/L.

What is the appropriate management for her diabetic ketoacidosis (DKA)?

MRCP2-1476

A 26-year-old female presents with one week of progressive and persistent double vision. She reports increasing tiredness at all times of day over the past 2 months and occasional chest tightness associated with palpitations. She has no past medical history. She was also adopted and unaware of any family history.

During examination, a loss of left eye abduction, right eye upwards gaze, and right eye adduction are observed. Systemic examination also reveals bilateral clammy hands and a heart rate of 120 per minute, irregular. What is the most likely diagnostic test?

MRCP2-1477

A 50-year-old female presents with light-headedness and abdominal pain. She has a medical history of asthma and takes regular beclometasone and as required salbutamol. On examination, her blood pressure is 95/75 mmHg and heart rate 115 beats per minute.

Blood results show:

– Hb 135 g/l
– Platelets 352 * 109/l
– WBC 14.2 * 109/l
– Neuts 10.3 * 109/l
– Lymphs 2.2 * 109/l
– Na+ 129 mmol/l
– K+ 5.2 mmol/l
– Urea 10.2 mmol/l
– Creatinine 115 µmol/l
– CRP 8 mg/l

A short Synacthen test is performed:

Time (minutes) 0 30 60
Cortisol (nmol/l) 150 165 212

A long Synacthen test is then performed:

Time (hours) 1 2 8 24
Cortisol (nmol/l) 202 420 820 1626

What is the most likely cause of her symptoms and abnormal test results?

MRCP2-1478

A 49-year-old woman presents with a 2-month history of fatigue, anorexia and nausea. She has also noticed some darkening of the skin on her hands. Prior to this, she was fit and well, with no significant past medical history. She has a strong family history of Graves’ disease.

On examination, there is some evidence of wasting of the face, and noticeable hyperpigmentation of the palmar creases. Her blood pressure is 105/75 mmHg. Blood tests are taken:

Na+ 134 mmol/L (135 – 145)
K+ 5.3 mmol/L (3.5 – 5.0)
Urea 6.8 mmol/L (2.0 – 7.0)
Creatinine 76 µmol/L (55 – 120)
Calcium 2.43 mmol/L (2.1-2.6)
Thyroid stimulating hormone (TSH) 1.2 mU/L (0.5-5.5)
Free thyroxine (T4) 13.3 pmol/L (9.0 – 18)

What subsequent test can be conducted to differentiate between a primary and secondary cause of the likely diagnosis?

MRCP2-1479

A 35-year-old alcoholic presents with abdominal pain and vomiting. His amylase is 1200 U/l and he is being treated for acute pancreatitis. You are called to see him as the nursing staff report the patient is becoming restless. He complains of numbness around his mouth and appears to be in some discomfort.

Your foundation year 2 colleague notes this morning’s blood results:

Adjusted calcium 1.8 mmol/l
Na+ 136 mmol/l
K+ 3.7 mmol/l
Urea 6.9 mmol/l
Creatinine 81 µmol/l

What is the next step in management?

MRCP2-1480

A 35-year-old woman presents to the hypertension clinic with difficult-to-control hypertension. She reports occasional aches and pains that mainly affect her arms and legs, as well as an increase in urinary frequency and urgency. Her blood pressure reading at the clinic is 175/95 mmHg. She is currently being treated with amlodipine and lisinopril for hypertension. Blood tests taken prior to her visit show normal electrolyte levels and mildly elevated creatinine. An aldosterone and renin test reveals an increased aldosterone-to-renin ratio, and a CT abdomen confirms bilateral adrenal hyperplasia. What is the most appropriate management for this patient?

MRCP2-1481

A 25-year-old woman with a history of partial Kallmann syndrome presents to the fertility clinic seeking advice on starting a family. She has been married for 6 months and has normal external genitalia, sparse pubic and axillary hair, and a body mass index of 23kg/m². What is the most suitable course of action for her?

MRCP2-1482

A 60-year-old man with a 35-year history of type 1 diabetes mellitus presents to the clinic for follow-up. He has peripheral diabetic sensory neuropathy, impotence, and has undergone laser therapy for bilateral diabetic retinopathy. His primary concern is experiencing unpredictable vomiting of undigested food, despite dietary modifications. During a previous hospitalization, erythromycin was effective in treating the condition. A barium swallow revealed significantly prolonged gastric emptying.

What is the most suitable long-term management plan for this patient?

MRCP2-1483

A 17-year-old male patient comes to the clinic with complaints of inadequate development of secondary sexual characteristics. Upon examination, you observe insufficient testicle growth and minimal axillary and pubic hair.

The blood test results are as follows:

Testosterone 2.5 nmol/L (6 -27)
FSH 4.2 IU/L (1.8 – 22.5)
LH 3.1 IU/L (1.2 – 103)

What is the probable diagnosis?