Archives: MRCP Part 2

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?

MRCP2-1332

An 80-year-old man with a history of localized squamous cell lung cancer presents to the Emergency Department with increasing confusion and peripheral muscle weakness. He reports feeling thirsty. Laboratory results show a hemoglobin level of 102 g/L, a white cell count of 12.1 x 10^9/L, and a platelet count of 167 x 10^9/L. His sodium level is 139 mmol/L, potassium level is 4.7 mmol/L, urea level is 6.2 mmol/L, creatinine level is 145 μmol/L, and calcium level is 3.2 mmol/L. His parathyroid hormone level is 1.9 pmol/L, which raises concern for pseudo hyperparathyroidism. After managing the acute hypercalcemia, what is the most appropriate long-term approach to treating the pseudo-hyperparathyroidism?

MRCP2-1301

You assess a 54-year-old man who reports having undergone pituitary surgery (and ‘some treatment’ after the operation), some time ago. He presents with complaints of feeling lethargic, having reduced energy and vitality.

Upon examination, you note increased central abdominal adiposity and reduced grip strength. The patient is currently on thyroid and cortisol replacement therapy, and blood tests indicate that these are at adequate levels. FBC, U&E, and LFTs are all within normal limits.

What would be the most appropriate investigation to conduct next?

MRCP2-1302

A 30-year-old woman visits the clinic with concerns about her menstrual cycle. She reports heavy bleeding and cramping during her periods, which occur every 2-3 weeks. On examination, her BMI is 27 kg/m2. Her BP is slightly elevated at 140/90 mmHg and her pulse is 85/min and regular. You notice excess hair growth on her chin and upper lip, as well as on her chest and lower abdomen. There are no signs of abdominal distension or tenderness. The examination of external genitalia is normal.
Upon further questioning, she reports difficulty getting pregnant despite trying for over a year.
Which of the following would be an appropriate initial investigation?

MRCP2-1303

A 28-year-old woman presents to her primary care physician with concerns about excessive hair growth and acne. She reports irregular periods and occasional use of oral contraceptives.
During the physical exam, her BMI is 30 and her blood pressure is slightly elevated at 140/88 mmHg. She has mild hair thinning on the front of her scalp, increased hair growth on her upper lip and chin, and hair growth around her nipples and lower abdomen.
Further testing reveals an increased LH/FSH ratio and a testosterone level of 4.5 nmol/l (normal range: 1-2.5 nmol/l). Which of the following tests is most likely to confirm the diagnosis in this case?

MRCP2-1304

A 65-year-old woman with a history of hypertension and occasional episodes of palpitations is seen in the clinic with unintentional weight loss and hand tremors. She is found to be clinically hyperthyroid. She takes lisinopril and metoprolol.
The following results are obtained from her investigations:

Thyroxine (T4) 110 pmol/l 11–22 pmol/l
Thyroid-stimulating hormone (TSH) < 0.01 µU/l 0.17–3.2 µU/l
A thyroid ultrasound with color flow Doppler reveals increased blood flow.
What would be the recommended next step in management?

MRCP2-1305

A 54-year-old woman presents with a history of weight gain and nocturia for the past six months. She has also developed a vulvar candidal infection recently. Her mother had diabetes and died of a stroke at the age of 76. On examination, her BMI is 35.2 kg/m2 and blood pressure is 130/82 mmHg. Dipstick urine reveals ++ glucose. Diabetes is confirmed with a fasting plasma glucose of 10.2 mmol/l and HbA1c of 66 mmol/mol (8.2%). What is the likely underlying pathological entity causing her diabetes?