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?

MRCP2-1411

A 32-year-old woman has been referred to a specialist due to her hypertension not responding to combination therapy with ramipril, amlodipine, bendroflumethiazide, and atenolol. During her clinic visit, her blood pressure is measured at 181/105 mmHg. She reports urinating more than 10 times per day and some of her blood test results are provided below. What is the probable diagnosis?

MRCP2-1412

A 57-year-old woman presents with a 4 month history of abdominal pains, low mood and constipation. She has a past medical history of hypertension and depression following the death of her husband 3 years ago. During a routine visit to her GP, blood tests are performed and upon review, the patient is referred to the hospital.

The blood test results are as follows:

Hb 100 g/l
Platelets 230 * 109/l
WBC 10 * 109/l
Calcium (adjusted) 2.96 mmol/l
Phosphate 1.35 mmol/l
Na+ 135 mmol/l
K+ 4.7 mmol/l
Urea 6 mmol/l
Creatinine 110 µmol/l
CRP 30 mg/l
Albumin 35 g/L

What is the first diagnostic test that should be conducted?

MRCP2-1413

A 26-year-old woman has been urgently referred to the endocrinology clinic due to her recent pregnancy. Despite taking oral contraceptives, she became pregnant and has been experiencing diarrhea for the past month. Her GP ordered blood tests and an antenatal referral, which revealed normal results for her full blood count, renal profile, and liver function tests. However, her TSH levels are undetectable and her free T4 levels are 52 pmol/l. Additionally, she has tested positive for thyroid-stimulating hormone receptor antibodies. The patient has no prior medical history. What is the most appropriate course of action for managing her hyperthyroidism?

MRCP2-1414

A 30-year-old woman presents to the emergency department with 4 days of fevers and sweating. She has a past medical history of Graves’ disease and is not compliant with medication treatment. She smokes ten cigarettes daily and works in advertising.

Her vital signs are heart rate 146 beats per minute, blood pressure 154/99 mmHg, respiratory rate 24/minute, oxygen saturations 97% on room air and temperature 38.4ºC.

During examination, she is diaphoretic, tremulous and confused (Glasgow coma scale 14/15). Proptosis and chemosis are noted on examination of her eyes. There are bilateral crackles on chest auscultation and her JVP is elevated.

Blood tests reveal:

Hb 124 g/L Male: (135-180)
Female: (115 – 160)
Platelets 189 * 109/L (150 – 400)
WBC 5.3 * 109/L (4.0 – 11.0)
Na+ 131 mmol/L (135 – 145)
K+ 4.2 mmol/L (3.5 – 5.0)
Urea 5.4 mmol/L (2.0 – 7.0)
Creatinine 89 µmol/L (55 – 120)
CRP 4 mg/L (< 5)
Bilirubin 26 µmol/L (3 – 17)
ALP 122 u/L (30 – 100)
ALT 99 u/L (3 – 40)
γGT 74 u/L (8 – 60)
Albumin 34 g/L (35 – 50)
TSH 0.0 mIU/L (0.2 – 5.5)
Free T4 81 pmol/L (10 – 24.5)

What is the most appropriate treatment option for the likely diagnosis?

MRCP2-1415

A 68-year-old man visits his primary care physician complaining of increasing confusion and lethargy. He has a medical history of depression, Barrett’s esophagus, and benign prostatic hyperplasia. The patient is currently taking sertraline 100mg, lansoprazole 30 mg twice daily, and tamsulosin 400 mg. The following are the results of his blood tests:

– Hemoglobin: 104 g/l
– Platelets: 168* 109/l
– White blood cells: 8.7* 109/l
– Neutrophils: 2.5* 109/l
– Lymphocytes: 3.0* 109/l
– Eosinophils: 0.6 * 109/l
– Sodium: 118 mmol/l
– Potassium: 4.1 mmol/l
– Urea: 7.9mmol/l
– Creatinine: 173 µmol/l
– Corrected calcium: 3.01mmol/l
– Total protein: 95g/l
– Albumin: 30g/l

In addition, his urinary sodium is 7 mmol/l, urinary osmolality is 100 mOsm/kg, and plasma osmolality is 280 mOsm/kg. What is the most likely cause of this patient’s hyponatremia?

MRCP2-1416

A 67-year-old man presents to the clinic for a review of his medical history. He has a past medical history of hypercholesterolaemia, hypertension, depression, and an NSTEMI. On examination, he appears to be euvolaemic. His current medications include sertraline, bisoprolol, ramipril, and furosemide.

The patient’s blood results show a Hb of 138 g/l, platelets of 440 * 109/l, WBC of 10.8 * 109/l, glucose of 6.5 mmol/l, and creatinine of 86 µmol/l. His total cholesterol is 6.5 * 109/l, and his fasting triglycerides are 12.5 mmol/L (normal < 1.7). Additionally, a paired serum and urine osmolarity test was performed, with the serum osmolarity at 290 mOsmol/kg (normal 275-295) and the urine osmolarity at 600 mOsmol/kg. The urine sodium level was 40 mmol/l. What is the most likely cause of the hyponatraemia in this 67-year-old man?