Archives: MRCP Part 2

MRCP2-1465

A 75-year-old male is admitted acutely unwell.

Four weeks prior to admission he had presented to the GP with tiredness and weight loss and had been diagnosed with hypothyroidism based on results which showed:

T4 8.2 pmol/L (10-22)

TSH 5.2 mU/L (0.4-5)

He was treated with thyroxine 75 micrograms daily and has since deteriorated. He has no other past medical history of note, does not smoke and drinks modest quantities of alcohol. He is married and is self-caring. His father had hypothyroidism.

On examination, he is drowsy, thin, has a temperature of 37.8°C, a pulse of 102 beats per minute and a blood pressure of 90/60 mmHg. Cardiovascular, respiratory and abdominal examination are otherwise normal. There are no neurological abnormalities.

The house officer has sent some emergency bloods on this patient.

Whilst awaiting the results, what is the most appropriate immediate treatment for this patient?

MRCP2-1466

A 16-year-old girl is brought to the emergency department by her mother, appearing terrified after experiencing her second episode of being unable to move upon waking in the morning. She reports no loss of consciousness and has no documented past medical history. Neurological examination is normal, and her body mass index is 19.5 kg/m². An ECG shows a jerky baseline with flat T waves. What is the likely diagnosis?

MRCP2-1467

A 70-year-old female presents with 4 days of general decline following a recent urinary tract infection, treated with oral antibiotics in the community by the GP. She is known to be a type 2 diabetic, diagnosed 26 years ago and insulin dependent for the past 5 years. She is normally on 48 units Lantus, 24 units TDS Novorapid.

On examination, she is disoriented in time and place, with a GCS of 14/15. There is no focal neurology, and chest and cardiovascular auscultation are unremarkable. Suprapubic tenderness is demonstrated on deep palpation, but the abdomen is otherwise soft and non-tender, with present bowel sounds. She appears extremely dehydrated, with dry mucous membranes, cool peripheries, a capillary refill time of 4 seconds, and JVP +1 cm above the angle of Louis.

Her blood sugar is 31 mmol/L, and a venous blood gas demonstrates pH 7.22, lactate 2 mmol/l, and ketones 5 mmol/l. A urine dip is awaited. What is the most likely diagnosis?

MRCP2-1468

A 15-year-old male presents with chronic headaches and visual blurring lasting for 4 months. He has no past medical history and no known family history. On examination, his heart sounds are normal with no added sounds and the respiratory examination is unremarkable. He has no focal neurological signs. Fundoscopy reveals papilloedema, hard exudates and flame haemorrhage. His blood pressure is 230/160 mmHg. His blood tests and arterial blood gas are as follows:

Na+ 145 mmol/l
K+ 2.8 mmol/l
Urea 5.2 mmol/l
Creatinine 70 µmol/l

pH 7.50
PaO2 13.2kPa
PaCO2 3.3 kPa
Bicarbonate 35 mmol/L

Serum ambulatory renin activity 0.3 pmol/L @ 3-4 hours (normal range 0.8-3.5 pmol/ml/hr)
Serum ambulatory aldosterone 25 pmol/L@ 3-4 hours (normal range 100-800)

What is the recommended long-term treatment for this patient?

MRCP2-1469

A 54-year-old male presents with a nine-month history of poor concentration, weight gain, and fatigue. He had a pituitary tumor resected three years ago and has been taking hydrocortisone 10 mg twice daily and thyroxine 150 mcg daily since then. On examination, there are no significant findings. Laboratory tests reveal a serum free T4 level of 12 pmol/L, a serum TSH level of <0.05 mU/L, a serum testosterone level of 7.3 nmol/L (normal range 10-30), and an IGF-1 level of 8.9 nmol/L (normal range 10-35). What is the most appropriate treatment for this patient?

MRCP2-1470

As the medical doctor on an acute medical unit, you receive a referral for a 27-year-old adopted female with a history of recurrent kidney stones who has been found to have hypokalaemia (K+ 2.6 mmol/l) by her GP. Despite feeling well and denying any vomiting or diarrhoea, her blood results show the following:

– Na+ 141 mmol/l
– K+ 2.6 mmol/l
– Bicarbonate 18 mmol/l
– Urea 5.0 mmol/l
– Creatinine 67 µmol/l
– Anion gap 13 mEq/L

What is the most likely cause of her presentation?

MRCP2-1471

A 29-year-old man comes to the clinic for a follow-up on his familial hypercholesterolaemia. He is currently taking 80mg of atorvastatin once daily.

Here are his recent blood test results:

Hb: 135 g/l
Platelets: 322 * 109/l
WBC: 10.5 * 109/l
Neuts: 6.2 * 109/l
Total cholesterol: 7.5 mmol/L (normal range < 5)
LDL cholesterol: 5.5 mmol/L (normal range < 3)
Na+: 138 mmol/l
K+: 4.6 mmol/l
Urea: 6.6 mmol/l
Creatinine: 72 µmol/l

What course of treatment would you recommend?

MRCP2-1472

A 67-year-old retired teacher was referred to the endocrine clinic by her primary care physician due to incidentally-detected hypercalcaemia. She had no significant medical history and was not taking any regular medications. Upon physical and systemic examination, no abnormalities were found.

Lab results:
– Urea: 7.5 mg/dl
– Calcium: 2.8 mmol/l
– Phosphate: 0.74mmol/l
– Creatinine: 98µmol/l
– Alkaline phosphatase: 450 IU/l

What investigation would be most helpful in establishing a diagnosis?

MRCP2-1473

A 67-year-old man presents with fever and difficulty urinating, along with burning pain and numbness ascending from his feet. He has a history of poorly controlled diabetes, hypertension, ischaemic heart disease, and hypercholesterolaemia. The patient is currently taking metformin, gliclazide, linagliptin, ramipril, aspirin, and simvastatin. Physical examination reveals mild suprapubic tenderness and decreased sensation in his feet. What is the recommended first-line treatment for his pain?

MRCP2-1474

A 30-year-old woman presents with recent weight gain, particularly on her face and abdomen. She reports irregular periods and was diagnosed with type 2 diabetes mellitus last year. The patient admits to consuming 15 units of alcohol daily. During examination, violaceous striae are observed on her abdomen, and proximal muscle weakness is evident. Blood tests reveal a sodium level of 143 mmol/L (135 – 145) and a potassium level of 2.8 mmol/L (3.5 – 5.0). The medical team suspects that the patient’s alcohol use may be the cause of her symptoms and wants to differentiate it from an endogenous cause. What is the most appropriate investigation?