Archives: MRCP Part 2

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?

MRCP2-1443

A 72-year-old man comes to the clinic for a follow-up appointment. He was recently diagnosed with type 2 diabetes after his GP conducted a screening. Despite being advised on dietary changes, his HbA1c levels have not improved. The patient has a medical history of bladder cancer, which was treated with chemotherapy, hypertension, macular degeneration, eczema, and chronic kidney disease. His baseline eGFR is 28 ml/min/1.73m2.

Lab results:
– Na+ 139 mmol/l
– K+ 4.4 mmol/l
– Urea 6.2 mmol/l
– Creatinine 214 µmol/l

What medication would be the most appropriate to initiate?

MRCP2-1420

A 30-year-old female presents to the emergency department with severe right flank pain that radiates to her groin. She was recently referred to the rheumatology department by her GP for investigation of joint pains, dry eyes, and dry mouth. She is not taking any regular medication.

Upon examination, her blood pressure is 132/68 mmHg, and abdominal examination reveals right flank tenderness. The following blood test results were obtained:

– Na+ 136 mmol/L (135 – 145)
– K+ 2.8 mmol/L (3.5 – 5.0)
– Urea 3.6 mmol/L (2.0 – 7.0)
– Creatinine 70 µmol/L (55 – 120)
– Bicarbonate 9 mmol/L (22 – 28)
– Chloride 116 mmol/L (95 – 105)
– Calcium 2.3 mmol/L (2.1-2.6)
– Phosphate 1.1 mmol/L (0.8-1.4)

What is the most likely diagnosis?

MRCP2-1421

A 35-year-old south Asian woman presents to the emergency department with complaints of abdominal pain and suspected constipation. Upon examination, there is no edema and her blood pressure is 105/68 mmHg. The initial blood results and subsequent tests are as follows:

pH: 7.250
Bicarbonate: 18.0 mmol/l
Base excess: -8.0 mmol/l
Anion gap: Normal

Potassium: 7.2 mmol/l
Creatinine: 56 mmol/l
Glucose: 5.3 mmol/l
Thyroid function: Normal
Aldosterone: Normal
Renin: Normal
Protein electrophoresis & immunoglobulins: Normal
Urinary sodium: 94 mmol/l (normal range >20 mmol/L)
Urinary potassium: 26.8 mmol/l (normal range >25 mmol/L)
17- hydroxyprogesterone: Normal
Short synacthen test (basal): 320 nmol/l
Short synacthen test (30 mins): 750 nmol/l

What is the most likely diagnosis for this 35-year-old south Asian woman?

MRCP2-1422

A 63-year-old man presents to the clinic with complaints of increasing fatigue and lethargy over the past few months. He has a medical history of chronic renal failure, which he has been managing for the past five years, as well as type 1 diabetes.

During the examination, his blood pressure is 135/75 mmHg, and his pulse is regular at 70 beats per minute. The patient has pale conjunctivae and peripheral neuropathy with sensory loss in both feet.

Further investigations reveal a haemoglobin level of 117 g/L (135-177), a white cell count of 8.1 ×109/L (4-11), and platelets of 199 ×109/L (150-400). His sodium level is 138 mmol/L (135-146), potassium is 5.3 mmol/L (3.5-5), creatinine is 210 µmol/L (79-118), alkaline phosphatase is 165 U/L (39-117), calcium is 2.05 mmol/L (2.20-2.61), and PTH is 22 pmol/L (1.2-7.6).

What is the most likely underlying diagnosis for this patient?

MRCP2-1423

A 50-year-old male visited his doctor complaining of sweating, fatigue, and daytime tiredness that had been going on for 5 months. He believed his rings were tight due to ‘fluid retention’ and had been experiencing worsening headaches and vision problems.

The patient was diagnosed with acromegaly and underwent surgery for the condition a month ago. He has been feeling good since then and has not reported any new symptoms.

What would be the most effective test for monitoring the effectiveness of his treatment?

MRCP2-1424

You are seeing a 55-year-old man with type 2 diabetes mellitus in the outpatient clinic. He has a past medical history of hypertension, mild left ventricular dysfunction and chronic kidney disease. He is currently on metformin and pioglitazone. Since last review he has gained 4kg in weight and his HbA1c has deteriorated to 68 mmol/mol from 60 mmol/mol. Body mass index today in clinic is 31 kg/m².

Recent blood tests are as follows:

Na+ 140 mmol/l
K+ 4.1 mmol/l
Urea 5 mmol/l
Creatinine 130 µmol/l

He was unable to previously tolerate exenatide due to injection site reactions. What would be the best alteration to his therapy?

MRCP2-1425

A 63-year-old man presents to the Emergency department with low impact fractures to two toes on his left foot. He has been taking canagliflozin for the past 6 months and has lost 5 kg in weight. His blood pressure has slightly decreased. On examination, his BP is 132/72 mmHg, pulse is 70/min and regular. His chest is clear, abdomen is soft and non-tender, and his BMI is 30. An x-ray confirms the fractures, and his creatinine is at the upper end of the normal range while his calcium level is 2.15 mmol/l (2.1-2.65). What is the most likely cause of the fractures?