Archives: MRCP Part 2

MRCP2-1233

A 47-year-old woman comes to the Medical Outpatient Clinic seeking advice. She has been taking atenolol for hypertension for the past two years. During her visit, she asks about hormone replacement therapy (HRT) as she suspects she may be going through menopause due to hot flashes, mood swings, and missed periods for the past six months. She has no history of thromboembolism, stroke, or breast cancer, but is concerned about the conflicting information she has read in the media regarding the risks of HRT, particularly in relation to deep venous thrombosis (DVT) and heart disease. What is the correct statement regarding combined oestrogen-progestin therapy for HRT?

MRCP2-1234

A 49-year-old woman presents to your clinic with concerns about osteoporosis. She underwent a hysterectomy and oophorectomy due to uterine fibroids a year ago and has been experiencing persistent and troublesome hot flushes since then. Her mother recently suffered a femoral neck fracture, which has increased the patient’s anxiety about her own risk of fractures in the future. She has no other significant medical history, is a non-smoker, drinks five units of alcohol per week, and maintains a healthy diet. On examination, she appears fit and thin with a BMI of 18 kg/m2, has a blood pressure of 122/88 mmHg, and normal breast examination. What recommendations would you make for her?

MRCP2-1235

A woman in her early 50s is undergoing treatment for symptomatic hypercalcemia related to squamous cell lung cancer (serum calcium 3.60 mmol/L). Despite initial measures of saline hydration and intravenous pamidronate, she is slow to respond. As she awaits surgical resection for her underlying cancer, what would be the most appropriate next step in her management?

MRCP2-1236

A 70-year-old man is recovering on the neurosurgical unit following a subdural haemorrhage. Five days earlier he underwent Burr hole surgery. You are consulted due to a persistently low sodium for the past two days. The following investigations were noted:

Day 3 post-surgery
Serum Na+ 118 mmol/l

Day 4 post-surgery
Serum Na+ 117 mmol/l
Urinary Na+ 30 mmol/l
Serum osmolality 282 mmol/l

Upon examination, the patient has dry mucous membranes and delayed capillary refill time.

What is the most likely diagnosis?

MRCP2-1237

A 70-year-old man with a history of high blood pressure, type 2 diabetes and hypercholesterolaemia was admitted to the emergency department with confusion. His daughter states that this has come on slowly over the last week and prior to this he had no memory problems. He currently takes metformin, ramipril, amlodipine and atorvastatin.

On examination, he smells strongly of urine and his mucous membranes appear dry. His abbreviated mental test score is 7 out of 10 and he is oriented in person but not in place or time. His heart rate is 95 per minute and his blood pressure is 105/62 mmHg. His chest is clear and has a soft ejection systolic murmur which does not radiate. His jugular venous pressure is not visible and he has mild ankle oedema. He has diffuse tenderness in the lower abdomen with no peritonism and normal bowel sounds. He has no focal neurology.

Investigation results are as follows:

Chest x-ray: Clear lung fields.

Urine dip:

Glucose +++
Blood +
Protein +
Leucocytes +
Nitrites +
Ketones +

Venous blood gas:

pH 7.43
BE – 1.5 mmol/l
HCO3 23 mmol/l
Glucose 34 mmol/l
Lactate 2.5 mmol/l

Full blood count:

Hb 120 g/l
Platelets 445 * 109/l
WBC 13 * 109/l

Renal function:

Na+ 151 mmol/l
K+ 5 mmol/l
Urea 10 mmol/l
Creatinine 137 µmol/l
Glucose 32 mmol/l
Ketones 2 mmol/l

What is the most appropriate initial resuscitation measure for this patient?

MRCP2-1238

A 67-year-old male was admitted with worsening agitation and confusion over the past week. He has a medical history of hypertension, ischaemic heart disease, and chronic back pain. His daughter noticed that he has lost approximately 1 stone in weight (currently weighs 71 kg), has been more fatigued over the last month, and has been drinking more water, which has led to urinary incontinence.

During examination, his heart rate was 108 beats/min, blood pressure was 95/42 mmHg, saturations were 94% on air, and respiratory rate was 20/min. He appeared dehydrated and had a Glasgow Coma Scale of 14.

The following blood results were obtained:

– Na+ 125 mmol/l
– K+ 5.0 mmol/l
– Urea 18 mmol/l
– Creatinine 180 µmol/l
– Blood glucose 34 mmol/l

A venous blood gas was performed, which showed:

– pH 7.32
– pCO2 4.6 kPa
– pO2 6.1 kPa
– HCO3 17 mmol/l
– BE -3.6 mmol/l

What is the most crucial treatment?

MRCP2-1239

A 35-year-old woman with a history of type 1 diabetes presents to the Emergency department with nausea and vomiting coupled with increased urinary frequency over the past 3 days. She has been progressively losing weight and reducing her insulin dose after starting empagliflozin prescribed to help her lose weight and reduce glucose fluctuations. She also admits to taking a Chinese herbal remedy for weight control.

Blood pressure is 100/70 mmHg, pulse is 88 beats per minute. pH is 7.25, glucose is 8.1 mmol/l, urine testing reveals ketones +++

What is the most likely diagnosis for this patient?

MRCP2-1240

A 16-year-old female presents with a six-month history of secondary amenorrhea and slight galactorrhea over the last three months. She had regular periods since menarche at the age of 11 until six months ago. She has been sexually active for approximately one year and has occasionally used condoms for contraception. She smokes five cigarettes daily and occasionally smokes cannabis. On examination, she appears clinically euthyroid, has a pulse of 70 bpm, and a blood pressure of 112/70 mmHg.

Investigations show:
– Serum estradiol 130 nmol/L (130-600)
– Serum LH 4.5 mU/L (2-20)
– Serum FSH 2.2 mU/L (2-20)
– Serum prolactin 6340 mU/L (50-450)
– Free T4 7.2 pmol/L (10-22)
– TSH 2.2 mU/L (0.4-5.0)

What is the most likely diagnosis?

MRCP2-1241

A 54-year-old female presents with galactorrhoea. Upon further questioning, she reports feeling extremely fatigued lately. She has no prior medical history and does not take any regular medications.

The following blood results were obtained:

Hb: 125 g/l
Platelets: 422 * 109/l
WBC: 9.2 * 109/l
Neuts: 6.2 * 109/l
Lymphs: 2.4 * 109/l
Na+: 132 mmol/l
K+: 3.8 mmol/l
Urea: 6.4 mmol/l
Creatinine: 41 µmol/l
CRP: 4 mg/l
Prolactin: 440 ng/dL (normal 5 – 40)

What diagnostic test will you order?

MRCP2-1242

A 37-year-old woman presents at 16 weeks gestation with a severe headache affecting the left side of her forehead and blurred vision in her left eye that occurred while on vacation in Spain. The symptoms resolved within 12 hours with paracetamol. She has a history of microprolactinoma, which was treated with cabergoline for three years and successfully stopped two years ago. She has no other significant medical history except for migraines for the past 15 years. On examination, her pulse is 78 beats per minute, blood pressure is 118/66 mmHg, and there is no galactorrhoea. Visual acuity, pupillary reflexes, and fields of vision are normal, as is the rest of the systemic examination. Investigations reveal elevated plasma prolactin levels and thyroid function tests within the normal range. What is the most appropriate management plan?