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?

MRCP2-1440

A 47-year-old man comes to the clinic for follow-up. He had presented to the emergency department two weeks ago with renal colic, which was confirmed to be nephrolithiasis through a spiral CT KUB. He was treated conservatively with IV fluids, analgesia, and an alpha-blocker, and his symptoms completely resolved before he was discharged.

Here are his blood test results:
– Hb: 142 g/l
– Platelets: 329 * 109/l
– WBC: 6.6 * 109/l
– Na+: 141 mmol/l
– K+: 3.8 mmol/l
– Urea: 6.2 mmol/l
– Creatinine: 71 µmol/l
– Corrected calcium: 2.71 mmol/l
– Parathyroid hormone: 10.2 pmol/l (normal range: 1.0-7.0 pmol/l)

What is the recommended course of action for this patient?

MRCP2-1441

A 55-year-old man comes to the endocrine clinic for a check-up. He has been taking metformin and gliclazide for his diabetes, but was also prescribed a GLP-1 mimetic six months ago due to poor control. He is hesitant to start insulin because he is a truck driver and fears losing his license. Previously, he tried metformin, gliclazide, and pioglitazone, but it did not improve his HbA1c levels.

His HbA1c has only decreased from 81 mmol/mol to 80 mmol/mol in the past six months, and he has lost two kilograms. What is the best course of action?

MRCP2-1442

A 67-year-old man presents to the endocrinology outpatient department with resistant hypertension and hypokalaemia. He is currently asymptomatic and has a medical history of hypercholesterolaemia. He smokes five cigarettes daily and drinks 2-3 bottles of wine per week. He is a non-executive director of a large multinational company. His blood tests reveal an increased aldosterone:renin ratio and a CT scan shows bilateral adrenal enlargement. What is the most suitable treatment for this patient?