Archives: MRCP Part 2

MRCP2-1484

A 42-year-old man presents to the Neurology clinic for assessment. He has a history of migraine with aura and is currently taking topiramate. No other medications are being taken. The following investigations were conducted:

– Na+ 138 mmol/L (135 – 145)
– K+ 3.1 mmol/L (3.5 – 5.0)
– Urea 5.7 mmol/L (2.0 – 7.0)
– Creatinine 78 µmol/L (55 – 120)

Venous blood gas:

– pH 7.29 (7.35 – 7.45)
– Bicarbonate 16 mmol/L (22 – 29)

Urinalysis:

– Glucose 3+
– Protein 2+
– Blood negative

What is the most likely diagnosis?

MRCP2-1485

A 45-year-old woman presents with a history of recurrent lethargy, shakiness, slurred speech, and diplopia for the past year. Her symptoms usually occur in the mornings and resolve after breakfast. She has a medical history of type 2 diabetes mellitus, alcohol excess, and a functional neurological disorder.

Upon observation, her SpO2 is 97% on room air, respiratory rate is 22 breaths/minute, blood pressure is 92/64, heart rate is 116 beats per minute, and she is apyrexial. Her capillary blood glucose is 5.2, but during the review, she becomes shaky and feels unwell. A repeat blood glucose test shows 2.4.

Blood tests are ordered, and 40% dextrose gel is administered. The results of the blood tests show insulin levels of 43 pmol/L (<25), C-peptide levels of 114 pmol/L (<75), and pro-insulin levels of 23 pmol/L (3.6-22). What is the most likely diagnosis?

MRCP2-1486

A 35-year-old male with a history of asthma and HIV visits the HIV clinic for a check-up. He has been experiencing weight gain, marks on his abdomen, and his partner has noticed a more heavy-set appearance in his face over the past two months. He was diagnosed with HIV at 21 years old after sharing needles and using heroin. He has been on retroviral treatment since he was 22, taking tenofovir, emtricitabine, atazanavir, and ritonavir, and has had good control. His asthma has been well managed with only salbutamol until six months ago when he started taking regular fluticasone due to recurrent exacerbation from upper respiratory tract infections. His recent blood tests show an undetectable viral load and a CD4 count of 900 cells/microliter. What is the most likely explanation for his symptoms?

MRCP2-1487

A 20-year-old woman presents to her GP with a 6 month history of weight loss, diarrhoea and palpitations. The diarrhoea is normal colour and over the last two months she has had roughly 2-3 bowel motions per day. The heart palpitations occur randomly throughout the day and night. She has also noticed that she has recently been getting episodes of feeling very hot and sweaty. She has no other past medical history and her only family history is a mother who has Hashimoto’s thyroiditis.

On examination, the patient is sweaty and her blood pressure is 130/80 mmHg, pulse is 102 bpm and regular, respiratory rate is 16/min and her oxygen SATs are 98% on air.

Blood tests are performed and reveal:

Hb 135 g/l
Platelets 220 * 109/l
WBC 7.1 * 109/l
Na+ 139 mmol/l
K+ 3.9 mmol/l
Urea 5.1 mmol/l
Creatinine 60 µmol/l
Free thyroxine (T4) 28 pmol/l
Thyroid stimulating hormone (TSH) 0.08 mu/l

A thyroid radioisotope scan is performed and reveals a globally reduced uptake.

What is the most likely diagnosis?

MRCP2-1488

A 40-year-old woman presents to the Endocrinology Clinic with a 4-month history of amenorrhoea. She reports having to wax her arms and upper lip and her mother went through early menopause at 28 after having an emergency hysterectomy post-partum. On examination, her body mass index is 38 kg/m² but otherwise unremarkable. Her GP has ordered blood tests prior to her appointment. Based on the following results, what is the most likely diagnosis?

Investigations:

LH 40 IU/L (5 to 25 IU/L)

FSH 8 IU/ (1 to 11 IU/L)

Estradiol 720 pmol/L (70-500 pmol/L)

Progesterone 220 nmol/L (35-92 nmol/L)

Thyroid Stimulating Hormone 5.6 mIU/L (0.5 -6.0 mIU/L)

Prolactin 700 mIU/L (105-548 mIU/L)

MRCP2-1489

A 32-year-old woman presents to your clinic with complaints of weight gain and irregular periods. Upon examination, her heart rate is 95 bpm and blood pressure is 155/92 mmHg. Her lab results show a low Hb level of 110 g/L, high MCV of 112 fl, and platelets within normal range at 199 * 109/L. Bilirubin and ALP levels are elevated at 17 µmol/L and 138 u/L, respectively, while ALT is slightly elevated at 55 u/L. Cortisol levels are high throughout the day, with a 9AM level of 461 nmol/L, midnight level of 154 nmol/L, and a rise to 645 nmol/L following an insulin stress test. Urine free cortisol is also elevated at 802 nmol/24h, while ACTH is within normal range at 13.3 pmol/L. Imaging studies show fatty changes in the liver but are otherwise unremarkable. What is the most likely diagnosis for this patient?

MRCP2-1461

A 25-year-old man is admitted with diabetic ketoacidosis. He is typically managed with basal bolus insulin but has missed several doses due to a busy work schedule. During examination, his respiratory rate is 30/min, he appears lethargic, disoriented, and has a distinct smell of acetone.
What arterial blood gas results would be most consistent with his presentation?

MRCP2-1462

A 50-year-old man presents with acute abdominal pain and a distended abdomen. He was given one litre of Hartmann’s solution in the Emergency Department. Upon examination, his pulse is 120 bpm, blood pressure is 70/40 mmHg, temperature is 39°C, and oxygen saturation is 93% on high-flow oxygen. He is also anuric. Arterial blood gases reveal a pH of 7.22, Base Excess of −13.5 mmol/L, lactate of 6.5 mmol/L, and K+ of 5.9 mmol/L. What should be the top priority in his immediate management?

MRCP2-1463

A 16-year-old female presents at the clinic for evaluation. Her 13-year-old sister was recently diagnosed with type 1 diabetes, and she is concerned about her own risk of developing the condition.

What is the most closely associated feature with the impending onset of type 1 diabetes?

MRCP2-1464

What is the proper procedure for conducting the oral glucose tolerance test (OGTT) to diagnose diabetes?