Archives: MRCP Part 2

MRCP2-1287

A 70-year-old Japanese male presents to the emergency department with sudden onset shortness of breath associated with palpitations. He has previously experienced similar palpitations 8 months ago but did not seek medical attention. He was last completely well and described by his son to be at baseline 24 hours ago when they had lunch together. The patient denies any chest pain, nausea, vomiting or sweating. On examination, the patient is pyrexic at 38.5 degrees and tachycardic, with a regular pulse at 130-140 beats per minute. Heart sounds demonstrate a gallop rhythm; auscultation of his chest reveals bibasal inspiratory coarse crackles and no wheeze. He has bilateral mild lower limb pitting oedema to low ankles. Examination of the abdominal and neurological systems is unremarkable. A chest radiograph demonstrates bibasal alveolar shadowing with mild bilateral pleural effusions. An ECG demonstrated sinus tachycardia at 130 beats per minute. Blood tests are as follows:

Hb 120 g/l
Platelets 280 * 109/l
WBC 8.5 * 109/l

Na+ 140 mmol/l
K+ 4.0 mmol/l
Urea 6.8 mmol/l
Creatinine 95 µmol/l

TSH < 0.01 mU/l
Free T4 135 pmol/l
Free T3 38 pmol/l

Nursing staff have kindly taken blood cultures and taken measures to cool the patient. What is the next most appropriate immediate treatment?

MRCP2-1288

A 67-year-old woman presents to the endocrinology department with complaints of enlarging hands and feet, difficulty wearing her usual rings, and changes in her facial appearance. She also reports persistent sweating and joint pain.

On examination, she has coarsened facial features, macroglossia, and spade-like hands and feet. Neurological examination reveals bitemporal hemianopia. Blood tests show elevated IGF-1 levels and failure to suppress growth hormone with an oral glucose load. An MRI reveals a large pituitary macroadenoma, which is partially removed through trans-sphenoidal surgery. However, the patient continues to experience sweating, arthralgia, and fatigue, and a repeat MRI shows residual tumor that is inaccessible to further surgical intervention.

Given the likely diagnosis, what is the most appropriate management at this point?

MRCP2-1289

You receive a call from a general practitioner regarding a 55-year-old man who has undergone thyroid function tests due to a history of weight loss. The results show TSH 0.01 mIU/L and T4 8.5 ug/dL, with no history of illicitly taking levothyroxine. Which of the following advice should you give?

MRCP2-1290

A 50-year-old woman presents to the hospital with abdominal pain and malaise. She has no medical history and does not take any regular medications or supplements. Upon blood tests, her calcium level is 2.70 mmol/l, phosphate level is 1.2 mmol/l, and creatinine level is 60 µmol/l. A chest X-ray shows normal appearances. The patient denies taking any medications or supplements, and her renal function is normal. Upon contacting the GP, it is discovered that her calcium was slightly elevated 10 years ago. Based on these findings, what is the most likely diagnosis?

MRCP2-1291

A 70-year-old male presents with confusion and drowsiness. His family reports a 5-day history of productive cough and shortness of breath. He has a medical history of type 2 diabetes mellitus, hypertension, and hypercholesterolemia. His regular medications include metformin 500 mg thrice daily, gliclazide 80 mg twice daily, amlodipine 5 mg daily, and simvastatin 40 mg nightly. Upon examination, he appears confused with dry mucous membranes, a blood pressure of 100/50 mmHg, a pulse of 110/min, a temperature of 37.6 oC, and a respiratory rate of 20/min. Crackles are heard at the right base, and his pulse is weak with a capillary refill of 3 seconds. Jugular venous pressure is not visible. Capillary blood glucose is found to be HI.

A venous blood sample is collected, revealing the following results:

Hb 129 g/l Na+ 161 mmol/l
Platelets 204 * 109/l K+ 4.9 mmol/l
WBC 13.1 * 109/l Urea 15.2 mmol/l
Neuts 11.9 * 109/l Creatinine 97 µmol/l
Glucose 56 mmol/l eGFR 62 mg/l
Ketones 1.9 mmol/l HbA1c 75 mmol/mol
pH 7.35 HCO3 20 mmol/mol

What would be your first course of treatment?

MRCP2-1292

A 20-year-old man with recently diagnosed type 1 diabetes and on insulin therapy for 8 weeks presents for a check-up. He is interested in participating in a metabolic intervention study that requires evaluation of his incretin response to a mixed meal test. Physical examination reveals no abnormalities. How does the incretin response in this individual compare to that of non-diabetic individuals?

MRCP2-1293

A 25-year-old woman presents to the emergency department with dyspnoea. She has a history of type 1 diabetes and is non-compliant with insulin treatment. She denies smoking or drinking alcohol and lives with her family.

Upon examination, her heart rate is 90 beats per minute, respiratory rate is 24/minute, blood pressure is 120/77 mmHg, and temperature is 36.7ºC. Arterial blood gas reveals a pH of 7.11 (7.35-7.45), pO2 of 14.1 kPa (11-13), pCO2 of 3.4 kPa (4.5-6), HCO3 of 10 mmol/L (22-26), glucose of 24 mmol/L (< 7.8), lactate of 2.6 mmol/L (0-2), potassium of 4.8 mmol/L (3.5-5.5), and sodium of 136 mmol/L (135-145). Blood ketones are elevated at 3.4 mmol/L (<0.6). The patient is treated with intravenous normal saline and appropriate potassium replacement, as well as a fixed rate insulin infusion (FRII) to normalize her academia, ketonemia, and hyperglycemia. During the resolution of this condition, what electrolyte abnormality is she at risk of developing?

MRCP2-1294

A 20-year-old man with type 1 diabetes and poor compliance presents to the hospital with shortness of breath, vomiting, and feeling unwell. He is diagnosed with diabetic ketoacidosis and is transferred to the high dependency unit. After a period of recovery, he starts to feel unwell on day 3 of his treatment. He experiences fatigue, lethargy, and muscle aches, and his legs collapse beneath him while walking to the bathroom.

Upon examination, he is alert with moist mucosa, and there are no fasciculations or myoclonus. He has 4/5 power in all muscle groups with retained sensation. His abdomen is soft, and his chest is clear. His observations show tachypnea at 24 breaths/min.

Admission blood tests reveal the following values compared to current values:
– Sodium: 128 mmol/l (current: 133 mmol/l)
– Potassium: 6.1 mmol/l (current: 4.5 mmol/l)
– Urea: 9.2 mmol/l (current: 5.6 mmol/l)
– Creatinine: 134 µmol/l (current: 87 µmol/l)
– Glucose: 27.1mmol/l (current: 12 mmol/l)
– Ketones: 3.1 mmol/l (current: 0.2 mmol/l)
– pH: 7.01 (current: 7.35)

What is the expected progression of his deterioration?

MRCP2-1295

A 72-year-old patient with type II diabetes visits her GP for a check-up. Her blood glucose levels are not well-controlled despite taking the highest doses of metformin and gliclazide. The GP decides to switch her from gliclazide to insulin glargine. What are the specific amino acid modifications present in glargine insulin?

MRCP2-1296

A 35-year-old nurse is admitted for prolonged fasting. She presented to clinic with a six-month history of episodic sweating and light-headedness, which were relieved by eating. During one of these episodes, her blood glucose level was measured at 2 mmol/L, and she quickly recovered after taking glucose tablets. On examination, no abnormalities were found, and her vital signs were within normal limits. She was admitted for a 72-hour fast, during which she developed typical symptoms 16 hours in. Her blood glucose level was measured at 2.2 mmol/L, and the fast was stopped. Blood tests revealed a plasma glucose level of 1.8 mmol/L, 3 beta-hydroxybutyrate level of 0.5 mmol/L, insulin level of 450 pmol/L, and C peptide level of 0.2 nmol/L. What is the most likely diagnosis?