Archives: MRCP Part 2

MRCP2-1417

A 16-year-old male presents with short stature and a previous diagnosis of slipped femoral epiphysis at the age of 10. His younger brother has also recently been diagnosed with bilateral slipped femoral capital epiphysis at the age of 11. Family history is otherwise unremarkable and his development and progress at school are normal. On examination, he is on the 12th centile for height, has a BMI of 30, and normal pubertal development. Investigations reveal normal blood pressure, haemoglobin, white cell count, platelets, serum sodium, serum potassium, serum creatinine, and PTH levels, but low serum calcium and high serum phosphate levels. What is the most likely explanation for this boy’s presentation?

MRCP2-1418

A 55-year-old woman presents to an endocrinology clinic with a history of previously controlled Grave’s disease on carbimazole. She reports experiencing diarrhoea, palpitations, and heat intolerance for the past two months. The patient is Postmenopausal and has no relevant past medical history or recent illness. Thyroid function tests performed by her general practitioner show a TSH level of 0.2 (0.5-5.5 mu/L) and a Free T4 level of 25.2 (9-18 pmol/L). On examination, the patient is warm, tachycardic, and has a smooth, non-tender goitre, but no eye signs are noted.

What is the most appropriate treatment?

MRCP2-1419

A 50-year-old male complains of frequent sweating and persistent headaches.

An oral glucose tolerance test is conducted and the results are as follows:

Time (mins) 0 30 60 90 120
Growth hormone (ng/ml) 2.1 2.3 3.0 3.5 3.6
Glucose 9.5 11.2 12.1 13.5 16.1

What additional investigation will be necessary in the future, given the probable diagnosis?

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?

MRCP2-1426

A 72-year-old male is admitted to the acute medical unit with a chest infection. His past medical history includes COPD and heart failure. His current medications include salbutamol, tiotropium, bisoprolol and ramipril. On examination you note right basal crepitations. The JVP is at 3 cm above the sternal angle. There is no peripheral oedema. His blood pressure is 150/90 mmHg.

You note that his blood results are as follows:

Na+ 122 mmol/l
Urine osmolarity 380 mosmol/l
Urine sodium 60 mosmol/l
Urea 5.8 mmol/l
Creatinine 60 µmol/l
fT3 5.8 pmol/l (normal range 3.5 – 7.8)
fT4 5.5 pmol/l (normal range 9.0 – 25.0)
TSH 0.1 mU/l (normal range 0.4 – 4.0)
morning cortisol normal

You water restrict the patient to 1.5 litres per day. On day 4 his bloods are reported as follows:

Na+ 120 mmol/l

What would be your plan of action for managing this patient?