Archives: MRCP Part 2

MRCP2-1340

A 61-year-old man is referred to the Emergency Department by his General Practitioner (GP). He has recently started lisinopril 10 mg for hypertension, and the GP is concerned by a deterioration in his creatinine level. According to the GP letter, he has had high blood pressure for the past ten years and was diagnosed with chronic kidney disease some two years ago.

On examination, in the Emergency Department, he appears to be in good health; his blood pressure is 140/90 mmHg, and pulse 80 bpm and regular.

Investigations:

Investigations Results Normal Values
Potassium (K+) 4.5 (4.2 mmol/l on ACEi initiation some 14 days ago) 3.5–5.0 mmol/l
Creatinine 190 µmol/l (170 µmol/l on ACEi initiation some 14 days ago) 50–120 µmol/l

What is the most appropriate course of action?

MRCP2-1341

You are asked to review a 70-year-old woman with a history of Type 2 diabetes who has been admitted to the medical ward with an episode of cellulitis. She is recovering and has just begun eating well, but nursing staff are concerned as she is suffering from recurrent episodes of hypoglycaemia during the early morning and in the late afternoon. Current diabetes therapy includes 20 units of mixed insulin BD, and 1 g of metformin BD. On examination her BP is 130/80, pulse is 72 and regular. There are signs of left sided cellulitis on examination of the leg. Abdominal examination reveals an area of lipohypertrophy in the right lower quadrant. A recent HbA1c on the computer is measured at 70 mmol/mol. A number of significant hypos are recorded in the range of 2.5 mmol/l – 3.3 mmol/l glucose, no values greater than 8.5 mmol/l are seen on her recording sheet.
What is the most appropriate course of action in this case?

MRCP2-1342

You assess a 29-year-old woman with Hashimoto’s thyroiditis at the thyroid clinic. She has been on a steady dose of 100 μg of thyroxine for the past few years, and her TSH was measured at 2.9 mU/l about 6 months ago (normal range 0.4-5). She is now 12 weeks pregnant, and you need to determine how to manage her thyroxine therapy during this pregnancy.

MRCP2-1343

A 32-year-old woman with type 1 diabetes presents with community acquired pneumonia. She has been feeling unwell for the past two days and has a temperature of 38.5 degrees Celsius. Despite managing to eat and drink, she is not consuming her usual amounts. Her CRB-65 score is zero, and she is prescribed oral antibiotics for home management.

The patient is on a basal bolus insulin regimen, with a total daily insulin dose of 40 units. You advise her to monitor her blood glucose and urinary ketone levels every four hours. If she experiences vomiting, is unable to keep fluids down, or cannot control her blood sugar or ketone levels, she should seek urgent medical advice.

The next day, the patient contacts the clinic as her blood sugar has increased to 15 mmol/L, and she has 1+ of ketones in her urine. She is drinking plenty of sugar-free fluids, not vomiting, and has been able to consume carbohydrates. She reports feeling no worse than the previous day.

What is the most appropriate advice to give in this situation?

MRCP2-1344

A 67-year old insulin controlled type 2 diabetic presents with symptoms of a flu-like illness. She has been feeling unwell for the past day and her intake of fluids and snacks has reduced compared to usual. She takes a mixed insulin twice a day and her daily insulin dose is 35 units. Her last HbA1c was 50 mmol/mol and her blood sugars over the last 24 hours have been between 6.0 and 8.0 mmol/L. You advise her to monitor her blood glucose every 4 hours and seek urgent medical advice if she starts vomiting, is unable to keep fluids down, or is unable to control her blood sugar. Later that day, she calls the clinic as her blood glucose has increased to 16 mmol/L, but she is still managing to drink fluids and eat carbohydrates as meal replacement. What is the most appropriate advice to give for managing her blood glucose levels?

MRCP2-1345

A 50-year-old woman had stage II breast cancer and underwent surgery, adjuvant chemotherapy and radiotherapy. The cancer was oestrogen receptor positive and progesterone receptor negative. After completing radiotherapy, she was prescribed tamoxifen. The patient had already gone through menopause before starting chemotherapy and is now experiencing severe hot flashes. What advice can you offer?

MRCP2-1346

A 35-year-old woman with a recent diagnosis of thyrotoxicosis presents with a sore throat. She has been taking carbimazole 40 mg daily and propranolol 40 mg bd for a month and initially felt better, but has been experiencing painful swallowing for the past week. On examination, she has a non-tender goitre and her pulse is regular at 80 beats per minute. Her blood tests show a low white cell count and neutrophil count, and elevated free T4 and TSH receptor antibody levels. What is the most appropriate treatment for this patient?

MRCP2-1347

What substance serves as an indicator of the process of bone formation?

MRCP2-1348

A 46-year-old teacher presents to a nephrology clinic for a routine review. She has been diagnosed with end stage renal failure due to focal segmental glomerular sclerosis (FSGS) on biopsy and is currently undergoing haemodialysis. The patient is of short stature and requires hearing aids for bilateral sensorineural hearing loss. Lately, she has been feeling more fatigued and lethargic. Her GP has recorded a fasting blood sugar level of 8.0mmol/l. The patient has a family history of diabetes in her mother and maternal grandmother, both of whom also experienced early onset hearing loss. Based on these findings, what is the most probable cause of her end stage renal failure?

MRCP2-1349

A 72-year-old man has routine blood tests that were requested by his primary care physician (PCP). He is incidentally found to have an elevated calcium level of 3.05 mmol/l. During discussion with his PCP, he reports experiencing constipation for the past 6 months and feeling more fatigued. He has had a poor appetite and sometimes feels nauseous. He also has abdominal distension, has not had a bowel movement in 5 days, and cannot recall passing gas in the last 24 hours. An abdominal x-ray is arranged via the surgical assessment unit, and his parathyroid hormone level is found to be high (7.5 pmol), which confirms primary hyperparathyroidism. What is the most probable cause of this patient’s primary hyperparathyroidism?