A 68-year-old male presents with a two-day history of nausea and vomiting. He reports eating a take away meal with his wife, who also became ill but has since recovered. The patient has a history of hypertension and takes amlodipine 5 mg daily. On examination, he appears comfortable with a temperature of 36.8°C, a pulse of 88 beats per minute regular, and a blood pressure of 150/100 mmHg. Laboratory investigations reveal elevated creatinine and corrected calcium levels. What is the recommended treatment for this patient?
MRCP2-1323
A 35-year-old man presented to the Emergency Department with a 3-month history of headache and visual disturbance. Urgent magnetic resonance imaging of the head revealed a pituitary adenoma. Baseline pituitary function tests were normal, except serum prolactin level of 12,000 mu/l (< 450 mu/l). Unfortunately, his symptoms failed to respond to both bromocriptine and cabergoline. Therefore, trans-sphenoidal surgery (TSS) was organized and undertaken successfully. However, in the first 6 hours post-surgery, his urine output was 2.8 liters. Otherwise, he was well, with no particular symptoms or complications. Urgent biochemical tests were performed. Results are shown below: s Plasma osmolality 290 mOsmol/kg 275 – 290 mOsmol/kg Urine osmolality 310 mOsmol/kg 50 – 1200 mOsmol/kg Sodium (Na+) 145 mmol/l 135 – 145 mmol/l Potassium (K+) 4.8 mmol/l 3.5 – 5.0 mmol/l Urea 6.5 mmol/l 2.5 – 6.5 mmol/l Creatinine (Cr) 100 μmol/l 50 – 120 µmol/l Glucose 6.0 mmol/l 3.9 – 7.1 mmol/l 0900 h cortisol 450 nmol/l 280 – 700 nmol/l What is the most appropriate initial therapy?
MRCP2-1324
A 25-year-old patient with type 1 diabetes is brought to the Emergency Department by their family. They have been experiencing flu-like symptoms for a few days. During examination, their GCS is 10, and they have a respiratory rate of 35/min. Finger-prick blood glucose in the department is measured at 33.8 mmol/l and this is confirmed on venous sampling. Arterial blood gases reveal a pH of 7.02 and serum bicarbonate of 10 mmol/l. Electrolytes are abnormal, with potassium of 6.2 mmol/l, urea of 16.8 mmol/l and creatinine of 200 mmol/l. They weigh 70kg. What would be the most appropriate initial treatment for this patient?
MRCP2-1325
A 65-year-old man is admitted to the Emergency Department after being found collapsed and disoriented at home. He is unable to provide a clear medical history, and he has no family members to assist. Upon examination, his Glasgow Coma Scale (GCS) is 10/15, his pupils are reactive, and there are no neurological signs. He has a fever of 38.5°C, is dehydrated, and has a pulse rate of 125/min with a blood pressure of 110/60 mmHg, which drops by approximately 10 mmHg when he changes position. Upon auscultation of his chest, heart sounds 1 and 2 are audible with no murmurs. He is hypoxic with O2 sats of 89% on air and has dullness to percussion in his right lower zone with coarse breath sounds. His abdomen is soft with audible bowel sounds. Ophthalmoscopy reveals microaneurysms and exudates. The Emergency Department nurse dipsticks his urine, which shows +++ Glucose, and a finger blood glucose test indicates a reading greater than 40. Emergency blood gas results and other biochemistry tests reveal high levels of serum sodium, urea, creatinine, and amylase, as well as low levels of plasma glucose and HbA1c. Despite receiving enough 0.9% saline to match his initial fluid deficit, his sodium levels remain high. What is the appropriate choice of IV fluid treatment at this stage?
MRCP2-1326
A 57-year-old man with chronic kidney disease is coming in for an arthroscopy of the right knee. Upon admission to the Emergency Department, his potassium levels are at 5.9 mmol/l, creatinine at 450 μmol/l, and urea at 28 mmol/l. What is the most appropriate course of action for his surgery?
MRCP2-1327
A 22-year-old female presents to the Endocrine Clinic with concerns about excessive hair growth on her face and upper chest. She reports irregular periods since menarche at age 13. On examination, her BMI is 26 kg/m2 and her testosterone level is 3.5 nmol/l (normal range: 0.5-3.0 nmol/l) with an elevated LH/FSH ratio. What is the optimal long-term treatment plan for this patient?
MRCP2-1328
A 35-year-old woman with a 20-year history of type 1 diabetes presents to the clinic with complaints of frequent falls. She has fainted twice and hit her head, requiring emergency department visits, and experiences dizziness at other times. She has a history of peripheral neuropathy and sexual dysfunction. Her medication regimen includes insulin glargine and mealtime Novorapid™, as well as ramipril 5 mg/day for renoprotection and indapamide 2.5 mg. On examination, her blood pressure is 140/85 mmHg with a postural drop of 30 mmHg systolic. She exhibits signs consistent with peripheral sensory neuropathy to the mid-shin. Investigations:
Haemoglobin 130 g/l 135–175 g/l White cell count (WCC) 6.0 × 109/l 4–11 × 109/l Platelets 180 × 109/l 150–400 × 109/l Sodium (Na+) 138 mmol/l 135–145 mmol/l Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l Creatinine 110 µmol/l 50–120 µmol/l HbA1c 48 mmol/ml (6.51%) < 53 mmol/mol (<7.0%)
What is the most appropriate next step in management?
MRCP2-1329
A 40-year-old woman with a history of Graves’ disease, managed with a block replace regimen, presents to the clinic for a follow-up appointment after four months of treatment. She complains of a rash on both shins, which is not painful but unsightly. During the examination, mild proptosis consistent with Graves’ eye disease is observed, along with a raised, indurated, and discolored rash over both tibiae. Her vital signs are stable, with a blood pressure of 135/72 mmHg and a regular pulse of 78.
The following investigations are conducted: – Hb 137 g/L (115-160) – WCC 9.9 ×109/L (4-11) – PLT 203 ×109/L (150-400) – Na 138 mmol/L (135-146) – K 3.9 mmol/L (3.5-5.0) – Cr 100 µmol/L (79-118) – TSH 1.2 IU/L (0.5-4.5)
What would be the most appropriate way to manage her rash?
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?