Archives: MRCP Part 2

MRCP2-1454

A 32-year-old male with a history of epilepsy, for which he is taking carbamazepine and has not had any seizures for the last two years, presents with irritability and nausea for the last 2 weeks. His wife says that he is often confused and seems to be lost most of the time. He takes alcohol occasionally and smokes ten to twelve cigarettes per day.

On examination, he is irritable but conscious and alert. Clinical examination revealed eczema over the face, shins and extensor surfaces of the forearms and a tattoo on the right shoulder. There was no evidence of any peripheral oedema.

Lab reports were as follows:

Hb 150 g/l
MCV 81 fl
MCH 31 pg
WBC 9 * 109/l
Plt 250 * 109/l
Urea 3.2 mmol/l
Creatinine 75 µmol/l
9:00 am Cortisol 345 nmol/l (170 700 nmol/l)
TSH 2.4 mU/l
Total T4 102 nmol/l (68 174 nmol/l)
Na+ 119 mmol/l
K+ 4.2 mmol/l

What would be the most appropriate initial management option?

MRCP2-1455

A 55-year-old patient with a history of hypertension undergoes neurosurgery for an intracranial haemorrhage. During the next few days, the patient’s serum sodium level gradually decreases and by the third day, it drops to 118 mmol/l despite being restricted to 1 L of fluids per day. The patient’s urine osmolarity is 700 mOsmo/l and urinary sodium is elevated at 80 mmol/l. What is the probable diagnosis?

MRCP2-1456

A 20-year-old nursing student is admitted to the hospital after collapsing at work. She denies any tongue biting or incontinence during the episode and was groggy but alert upon regaining consciousness. According to her mother, the patient has experienced two previous episodes of collapse.

The nursing student’s vital signs include a blood pressure of 127/77 mmHg, a heart rate of 81 bpm, and oxygen saturation of 97%.

What is the initial investigation that should be performed?

MRCP2-1457

A 20-year-old woman comes in for a check-up. She has a medical history of 11-beta-hydroxylase deficiency and hypertension, which is being treated with ramipril and indapamide. The deficiency was discovered at birth due to clitoromegaly.

What is the most significant elevation expected?

MRCP2-1458

An 80-year-old male attends the diabetes clinic with longstanding type 2 diabetes. He has been experiencing recurrent nausea and vomiting, and has been diagnosed with gastroparesis. Despite being on metoclopramide, his symptoms have not improved and he has lost 10% of his weight over the past year. His HbA1c has improved from 7.6% to 6.2% over the past year. He has chronic kidney disease stage 3 and aortic stenosis, and is currently on Humulin M3, metformin, ramipril, bendroflumethiazide, and aspirin. He lives alone and has had 3 falls in the past month, with difficulty getting up in the morning and low mood. His blood sugar readings have been fluctuating, with some readings as low as 3.1 mmol/l and as high as 16.1 mmol/l.

What is the next appropriate step in managing his diabetes?

MRCP2-1459

A 50-year-old woman visits her primary care physician complaining of headaches that have been bothering her for the past six months. She also mentions that her wedding ring no longer fits and that her hands have been swelling. She has no medical history to report.

During the examination, the physician observes that her brow and jaw are protruding, and there is swelling in her hands. Her blood pressure is 165/78 mmHg.

Blood test results show an HbA1c level of 52 mmol/mol (<48). What is the primary investigation that should be conducted considering the probable diagnosis?

MRCP2-1460

You assess a 29-year-old woman who is 24 weeks pregnant. Due to her BMI of 33 kg/m², she underwent a routine oral glucose tolerance test which yielded the following results:

Time (hours) Blood glucose (mmol/l)
0 7.8
2 10.6

Apart from this, there have been no other complications during her pregnancy and her anomaly scan showed no abnormalities. What would be the best course of action?

MRCP2-1427

An elderly female presents with a 2 week history of breathlessness. Her past medical history includes diet-controlled type 2 diabetes, ischaemic heart disease, hypothyroidism and depression. Her medication list includes levothyroxine, aspirin, simvastatin, ramipril, bisoprolol and citalopram. Observations on presentation to Emergency Department are as follows: respiratory rate 26/min, saturations 94% (on 4 litres oxygen via Venturi), heart rate 80 beats per minute, blood pressure 156/82 mmHg. Auscultation demonstrates crackles at the left base with no wheeze. The abdomen is soft and non-tender. There is no oedema peripherally.

Blood results on admission are provided below:

Hb 134 g/l
Platelets 172 * 109/l
WBC 13.3 * 109/l
Na+ 128 mmol/l
K+ 5.1 mmol/l
Urea 13 mmol/l
Creatinine 178 µmol/l
Serum osmolality 220 mosm/kg
Urinary sodium 50 mEq//l

What is the most likely cause of hyponatraemia in this elderly female patient?

MRCP2-1428

A 75-year-old man who has smoked 20 cigarettes per day presents with a persistent cough, weight loss, and drowsiness. His test results reveal:

– Sodium (Na+): 115 mmol/l (normal range: 135-145 mmol/l)
– Potassium (K+): 5.1 mmol/l (normal range: 3.5-5.0 mmol/l)
– Urea: 3 mmol/l (normal range: 2.0-7 mmol/l)
– Creatinine: 74 µmol/l (normal range: 55-120 µmol/l)
– Plasma osmolality: 270 mOsm/kg (normal range: 285-295 mOsm/kg)
– Urine osmolality: 1210 (normal range: 500-800 mOsm/kg)

What is the most probable diagnosis?

MRCP2-1429

A 72 year old man was admitted to hospital with symptoms of shortness of breath, productive cough and palpitations. Upon examination, a chest x-ray revealed a left lower lobe pneumonia and an ECG showed atrial fibrillation with a fast ventricular response. The patient was treated with intravenous antibiotics, fluids and oral digoxin loading, which resulted in significant improvement in his condition. During a follow-up examination, a repeat ECG showed that the patient had cardioverted back to sinus rhythm and digoxin therapy was discontinued. Thyroid function tests were ordered to investigate the underlying cause of atrial fibrillation, with the following results:

– Haemoglobin: 130 g/dL
– White cell count: 12.5* 109/L
– Neutrophils: 10.8* 109/L
– Platelets: 320* 109/L
– Urea: 4.2 mmol/L
– Creatinine: 120 micromol/L
– Sodium: 140 mmol/L
– Potassium: 3.8 mmol/L
– C-reactive protein: 95 mg/L
– Thyroid stimulating hormone: 0.3 microU/L
– T4 free serum: 13.8 pmol/L
– T3 free serum: 6.9 pmol/L

What is the most appropriate next investigation to assess the patient’s deranged thyroid function tests?