Archives: MRCP Part 2

MRCP2-1385

A 75-year-old man presents to his GP with left flank pain and intermittent sweats that improve with eating. He has also fainted between meals. A technically difficult ultrasound reveals a 3 cm mass in the tail of the pancreas. A CT scan confirms the mass and blood biochemistry is normal. A blood glucose test after an overnight fast and exercise bike session shows a reading of 2 mmol/l. A CT guided needle biopsy of the pancreas shows ill-defined nests of cells that stain positive for chromogranin and synaptophysin. What is the most likely diagnosis?

MRCP2-1386

A 55-year-old male presents to the endocrine clinic for his annual review. Six years ago, he was diagnosed with a large pituitary tumor after experiencing visual field defects. He underwent successful surgical removal of a non-functioning pituitary tumor and received cranial irradiation radiotherapy. postoperative assessment revealed partial hypopituitarism, and he has been managing well on hydrocortisone 10 mg BD and thyroxine 150 µg daily since then. However, he has noticed a lack of libido. Serial MRI scans have shown no recurrence of the tumor.

The endocrine nurse performed some investigations prior to the clinic, and the results are as follows: random serum cortisol 768 nmol/L (120-600), free T4 21.2 pmol/L (10-22), TSH <0.05 mU/L (0.4-5), LH 1.1 mU/L (1-10), FSH 0.5 mU/L (1-10), IGF-1 7.8 nmol/L (18-37), and testosterone 7 nmol/L (9-35). Additionally, a DEXA scan requested by the SpR at the last appointment revealed average T scores of −2.3 and −2.1 at the hip and spine, respectively. What is the most appropriate treatment to prevent the progression of his bone loss?

MRCP2-1387

A 23-year-old student presents to the Emergency department with a productive cough of rusty coloured sputum. She has been experiencing increased shortness of breath, night sweats and fevers for the past 48 hours. The patient is currently taking daily hydrocortisone for congenital adrenal hyperplasia and the combined oral contraceptive pill. The following blood results were obtained:

Hb 131 g/l Na+ 134 mmol/l
Platelets 201 * 109/l K+ 4.1 mmol/l
WBC 14.9 * 109/l Urea 7.0 mmol/l
Neuts 10.1 * 109/l Creatinine 82 µmol/l
Lymphs 1.2 * 109/l CRP 185 mg/l
Eosin 0.4 * 109/l

What is the most appropriate way to manage her steroid hormone replacement?

MRCP2-1388

A 56-year-old man comes to the diabetes clinic for evaluation. He has been experiencing symptoms of polyuria, polydipsia, and lethargy for the past few months, and his fasting glucose level is elevated at 7.8 mmol/l. He has no family history of diabetes and is currently being treated for hypertension and dyslipidemia by his primary care physician. During the examination, his blood pressure is 150/90 mmHg, his pulse is regular at 72 beats per minute, and his body mass index is 33 kg/m². His renal function is normal, and he tests positive for GAD+ antibodies.

What is the most appropriate approach to managing his glucose control?

MRCP2-1389

A 28-year-old woman has been referred to the endocrinology clinic due to complaints of palpitations over the last three weeks. An ECG during an episode of palpitation revealed sinus tachycardia, which resolved with a Valsalva manoeuvre. She was offered beta-blockers but declined. She has no past medical history and does not take any regular medications except for over the counter beta-blockers and an oral contraceptive pill. She drinks roughly two units of alcohol per week but does not smoke. On examination, she has a non-tender goitre. Biochemical investigations reveal an undetectable TSH, free T4 of 46ng/dl, and positive thyroid-stimulating hormone receptor antibodies. She is keen to start treatment after noticing the goitre and opts for carbimazole treatment to induce remission. She is warned that if she experiences a sore throat or any infection, she must have blood tests to exclude agranulocytosis. What other symptoms should she be warned about?

MRCP2-1390

A 70-year-old woman is admitted to the acute medical unit due to concerns of exposure to the chickenpox virus. Her GP referred her after she had contact with her grandson who currently has a generalised vesicular rash. The patient has a medical history of heart failure and giant cell arteritis and is currently taking prednisolone, ramipril, and bisoprolol, with a dosage of 40mg for the past two weeks. What is the appropriate management for this patient?

MRCP2-1391

A 30-year-old woman with type 1 diabetes since the age of 18 has an urgent appointment in the diabetes clinic. She has been managing her diabetes well with insulin and has no other medical issues. However, she recently discovered that she is pregnant and is worried about any potential harm to the fetus. She has no intention of terminating the pregnancy. She took two pregnancy tests after missing her period one week ago, both of which were positive. She has been taking a basal-bolus insulin regimen and atorvastatin. Her retinal screening and urine testing were done nine months ago, and her HbA1c was last measured three months ago at 39 mmol/mol. She has been advised to continue with her insulin but has stopped taking atorvastatin due to concerns about its effects during pregnancy. What is the best course of action to prevent diabetes-related complications?

MRCP2-1392

A 42-year-old woman has had a total thyroidectomy for a 3.2cm papillary thyroid tumour without lymph node or metastatic involvement and negative margins. She is seeking advice on the most appropriate monitoring for recurrence of malignancy during her follow-up appointment with the endocrinology clinic.

MRCP2-1393

A 28-year-old woman presents to the endocrinology clinic with concerns about her missed period despite a negative pregnancy test. Blood tests reveal an undetectable TSH and a free T4 level of 48 ng/dl. She has a medical history of hepatitis C, but no chronic liver disease. Further investigations show negative thyroid-stimulating hormone receptor antibodies and a radionuclide thyroid uptake scan indicating diffuse thyroid uptake. The diagnosis is Graves’ disease. Due to her history of hepatitis C, she chooses radioiodine treatment. While being advised to avoid children during treatment, she wonders about her chances of conceiving after treatment. What is the most appropriate advice to give her?

MRCP2-1394

A 26-year-old woman is ready to leave the hospital after being admitted for four days due to feeling unwell for a month with symptoms of vomiting, postural dizziness, and weight loss. Addison’s disease was diagnosed after a Synacthen test, and she was prescribed hydrocortisone three times a day and fludrocortisone daily. She has no medical history or prior treatments. Her hydrocortisone doses are 10mg at 09:00 and 5mg at 12:00 and 15:00. She mentions to the medical team that she occasionally works night shifts. What is the appropriate advice regarding steroid dosing for night shifts?