Archives: MRCP Part 2

MRCP2-1333

A 20-year-old female presents with recurrent episodes of cystitis despite treatment with trimethoprim. She has a history of diabetes mellitus since the age of 12 and is currently on twice daily mixed insulin. Additionally, she has been taking oral contraceptives for the past two years and smokes 10 cigarettes per day. Her two elder brothers are healthy. On examination, she appears thin but well with a BMI of 21.5 kg/m2, a blood pressure of 108/76 mmHg, and normal cardiovascular, respiratory, and abdominal findings.

Laboratory investigations reveal serum sodium of 140 mmol/L (137-144), serum potassium of 4.5 mmol/L (3.5-4.9), serum urea of 5.6 mmol/L (2.5-7.5), serum creatinine of 95 µmol/L (60-110), fasting plasma glucose of 10.2 mmol/L (3.0-6.0), and HbA1c of 87 mmol/mol (20-42) or 10.1% (3.8-6.4). An ultrasound of the abdomen suggests reflux nephropathy.

What is the optimal treatment plan to preserve her renal function?

MRCP2-1334

A 28-year-old female with a history of successfully treated thyrotoxicosis experienced a relapse in the third trimester of her pregnancy. She was briefly treated with carbimazole but had to discontinue due to intolerance. Now four weeks postpartum, she continues to experience symptoms such as tremors, sweats, palpitations, weight loss, and flushing. She wishes to breastfeed her healthy infant boy. On examination, she has a fine tremor, a pulse rate of 110/min-1, and lid lag. She also has a palpable goitre with an audible bruit and exhibits exophthalmos, chemosis, and lid-lag upon eye examination. Her lab results show a low TSH level and high free T4 and T3 levels. What is the most appropriate treatment for her thyrotoxicosis?

MRCP2-1335

A 32-year-old female is referred by her GP, being 10 weeks pregnant.

Three months ago, she was diagnosed with thyrotoxicosis with an elevated T4 concentration and suppressed TSH concentration. Her GP started her on carbimazole at that time.

During her presentation, she has a pulse of 90 beats per minute, a fine tremor, and lid lag. Her blood pressure is 118/80 mmHg, and she has a palpable goitre.

What is the most appropriate treatment for this patient?

MRCP2-1336

A 28-year-old woman who is 22 weeks’ pregnant with her second child presents to the clinic with complaints of anxiety and palpitations. She is worried about her ability to maintain a healthy weight. During the examination, you notice a nodule on the left side of her thyroid. Her blood pressure is 135/70 mmHg, and her resting pulse is 88/min.

The following investigations were conducted:

– Haemoglobin (Hb): 114 g/l (normal range: 115–155 g/l)
– White cell count (WCC): 5.9 × 109/l (normal range: 4.0–11.0 × 109/l)
– Platelets (PLT): 172 × 109/l (normal range: 150–400 × 109/l)
– Sodium (Na+): 141 mmol/l (normal range: 135–145 mmol/l)
– Potassium (K+): 4.0 mmol/l (normal range: 3.5–5.0 mmol/l)
– Creatinine (Cr): 95 µmol/l (normal range: 50–120 µmol/l)
– TSH: < 0.05 (normal range: < 0.5–4.5)
– Free T4: 31 pmol/l (normal range: 10–22 pmol/l)

An ultrasound revealed a solitary left-sided thyroid nodule, and a fine-needle aspiration (FNA) revealed an adenoma. What is the most appropriate management for this patient?

MRCP2-1337

A 32-year-old pregnant woman presents with symptoms of hyperthyroidism at 28 weeks of gestation. She reports feeling anxious, experiencing palpitations, heat intolerance, and difficulty maintaining her weight during pregnancy. On examination, her blood pressure is 118/72 mmHg, with a regular pulse of 100/min. No goitre is observed during neck examination.
Investigations:

Haemoglobin 122 g/l 115–155 g/l
White cell count (WCC) 6.0 × 109/l 4–11 × 109/l
Platelets 180 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine 88 μmol/l 50–120 µmol/l
Thyroid stimulating hormone (TSH) <0.05 μU/l 0.17–3.2 µU/l
Anti-thyroid antibodies +ve

What is the recommended management plan for this patient?

MRCP2-1338

A 35-year-old woman visits the Endocrinology Clinic complaining of restlessness and weight loss. She reports experiencing heart palpitations and has seen her GP three times in the past six months, receiving a prescription for a selective serotonin uptake inhibitor (SSRI) with no improvement in her symptoms. On examination, her BP is 118/72 mmHg, pulse is 92 bpm and regular, and she has a fine tremor. Thyroid function tests reveal the following results: TSH 0.03 µU/l (normal range 0.17–3.2 µU/l), free T4 21.5 pmol/l (normal range 11–22 pmol/l), and free T3 13.2 pmol/l (normal range 3.5–5 pmol/l). What is the most appropriate treatment for this patients underlying condition?

MRCP2-1339

A 72-year-old man comes to the clinic for follow-up. He recently experienced an inferior myocardial infarction that was treated with angioplasty and stenting, and he now has mild residual heart failure. He is currently taking a BD mixed insulin and metformin, which was previously well controlled. However, he has lost weight over the past few months and is now experiencing troublesome hypoglycemia in the mid-afternoon.

During the examination, his BMI is 27, his blood pressure is 125/72 mmHg, his pulse is 75 and regular, and he is not in cardiac failure. The following investigations were conducted:

– Haemoglobin: 137 g/L (135-177)
– White cell count: 8.9 ×109/L (4-11)
– Platelets: 169 ×109/L (150-400)
– Sodium: 139 mmol/L (135-146)
– Potassium: 4.8 mmol/L (3.5-5)
– Creatinine: 129 μmol/L (79-118)
– HbA1c: 42 mmol/mol (<42) or 6.0% (<6.0) What is the most appropriate way to manage this 72-year-old man?

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.