Archives: MRCP Part 2

MRCP2-1318

A 40-year-old woman is referred to the endocrine clinic due to symptoms of weight gain, lethargy, dry cough, and hoarse voice over the past 3 months. She has a history of bipolar disorder and is currently taking lithium. On examination, she has patchy hair loss, a smooth goitre, and is overweight with a body mass index of 32 kg/m². Her blood pressure is 122/82 mmHg, and her pulse is 60 beats per minute. Laboratory investigations reveal a sodium level of 130 mmol/l and a TSH level of 14.2 mIU/l. What is the most appropriate management plan for this patient?

MRCP2-1319

A 50 year-old female presents to the clinic referred by her primary care physician. She reports experiencing fatigue, weight loss, and increased sweating over the past four months. Additionally, she has noticed a decrease in her sex drive.

During the examination, the patient appears pale and has a pulse rate of 121 beats per minute with a bounding pulse character. Her blood pressure is 118/79 mmHg, and heart sounds 1 and 2 are present with no added sounds. The patient’s chest is clear, and her abdomen is soft and non-tender with no organomegaly. She has a smooth goitre but no signs of thyroid eye disease. Examination of her cranial nerves is normal.

Recent blood tests reveal the following results:

– Hb: 11.3 g/dl
– Platelets: 190 * 109/l
– WBC: 10.9 * 109/l
– Na+: 129 mmol/l
– K+: 4.3 mmol/l
– Urea: 7.9 mmol/l
– Creatinine: 94 µmol/l
– ALP: 155 u/l
– Calcium: 2.40 mmol/l
– Albumin: 40 g/L
– TSH: 11 mU/L
– Free T4: 41 pmol/L
– Free T3: 11 pmol/L

What is the most likely diagnosis for this patient?

MRCP2-1320

A 50-year-old man has been diagnosed with atrial fibrillation and started taking amiodarone two years ago. Prior to starting amiodarone, his thyroid function tests were normal. However, he developed hyperthyroidism while taking amiodarone. Four months ago, he stopped taking amiodarone and started taking 40 mg carbimazole once daily, but he continued to lose weight despite having a good appetite. He is also taking digoxin 250 micrograms once daily and warfarin as per INR. There is no family history of thyroid disease. On examination, his pulse is 92 beats per minute, irregularly irregular, and his blood pressure is 130/70 mmHg. There is no goitre palpable on neck examination and he has no visible tremors.

The following investigations were conducted:
– Serum sodium: 138 mmol/L (137-144)
– Serum potassium: 4.1 mmol/L (3.5-4.9)
– Serum urea: 3.8 mmol/L (2.5-7.5)
– Serum creatinine: 88 µmol/L (60-110)
– Plasma free T4: 56 pmol/L (10-22)
– Plasma free T3: 14.2 pmol/L (5-10)
– Plasma thyroid-stimulating hormone: <0.02 mU/L (0.4-5)
– Serum antithyroid peroxidase: 12 U/mL (<50)
– TSH receptor antibodies: <1 U/L (<7)
– Radioactive iodine uptake scan (off carbimazole) revealed less than 1% uptake by thyroid gland.

What is the most appropriate management for this patient?

MRCP2-1321

A 35-year-old man visits his primary care physician (PCP) complaining of a two week history of a sore throat accompanied by fatigue, a decreased appetite and general viral symptoms. He has also experienced frequent heart palpitations and increased sweating, but these symptoms are now improving, with the patient reporting occasional palpitations. Other symptoms include pain in the lower part of his neck that worsens with swallowing and occasional hoarseness of his voice. He is in good health, not taking any medications, and does not smoke. There is no significant family history. The only positive findings on examination were residual tenderness over his lower anterior neck to palpation and mild tachycardia associated with warm skin to touch. No lymphadenopathy was palpable.
Thyroid function tests (TFT) show a T4 level slightly above normal and a TSH level of < 0.1 mU/l. The PCP diagnoses a viral illness and prescribes carbimazole 20 mg twice a day based on the TFT results. Two months later, the patient returns to his PCP complaining of increased fatigue, weight gain, and minor discomfort in the lower part of his neck.
What would be the next most appropriate course of action?

MRCP2-1322

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?