Archives: MRCP Part 2

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?

MRCP2-1350

A 36-year-old man presents to the endocrine clinic following his second episode of acute pancreatitis. During his follow-up appointment with the surgical registrar, it was noted that his fasting triglycerides were 8.2 mmol/l (0.7-2.1), despite his LDL level not being particularly raised. On examination, his blood pressure is 125/70 mmHg, his pulse is 70 and regular, and he has a BMI of 23. Additionally, there is evidence of eruptive xanthomas on his skin. What is the most appropriate therapy for him?

MRCP2-1330

An 80-year-old woman presents to a new General Practitioner (GP) for routine blood tests. The GP notices a raised corrected calcium level of 2.80 mmol/l and a raised parathyroid hormone (PTH) at 9 pmol/l. There is no history of renal stones, fractures or psychiatric disturbance. Other renal and liver function testing is unremarkable, full blood count is normal and there is no suspicion of underlying malignancy. Bone mineral density is at the lower end of the normal range. What is the most appropriate way to manage this patient?

MRCP2-1331

A 68-year-old man presents to the medical outpatient clinic with complaints of fatigue and tenderness in his neck. He was hospitalized six months ago for angina associated with atrial flutter, which resolved with intravenous digoxin. Currently, he is taking amiodarone 200 mg daily, aspirin 75 mg daily, atenolol 50 mg daily, and pravastatin 40 mg daily. His recent 24-hour ECG shows sinus rhythm with occasional ventricular ectopics. On examination, he has a fine tremor, a pulse of 56 beats per minute, and a blood pressure of 146/88 mmHg. Mild tenderness is noted in the thyroid area, but there is no obvious goitre. Laboratory investigations reveal a plasma free T4 level of 33.1 pmol/L (normal range: 10-22) and a plasma TSH level of <0.02 mU/L (normal range: 0.4-5). What is the optimal management plan for this patient?