Archives: MRCP Part 2

MRCP2-1243

A 42-year-old man presents with complaints of decreased sexual desire and difficulty achieving orgasm. He reports feeling stressed at work and having trouble balancing his responsibilities at home. Blood tests from his primary care physician show normal thyroid function, but elevated prolactin levels at 2800 mU/l (< 360) and low testosterone levels. He admits to drinking two glasses of wine per night. There are no reported visual disturbances.
What is the most probable cause of his impotence?

MRCP2-1244

A 56-year-old man is being seen in clinic due to resistant hypertension despite being treated with ramipril, amlodipine, indapamide, and bisoprolol. He appears comfortable at rest.

Observations:

– Temperature: 36.5ºC
– Blood pressure: 182/125 mmHg
– Heart rate: 88/min
– Respiratory rate: 16/min
– Saturations: 97% on air

Investigations:

– Na+: 148 mmol/l
– K+: 2.9 mmol/l
– Urea: 6.5 mmol/l
– Creatinine: 92 µmol/l
– Renin: Low
– Aldosterone (supine): High
– Aldosterone (prolonged standing): Increase from supine levels

Blood gases:

– PaO2: 11.2kPa
– PaCO2: 5.2kPa
– pH: 7.49
– HC03-: 32 mmol/l
– BE: +4

What is the most likely diagnosis for this patient?

MRCP2-1245

A 50-year-old man presents to the Emergency Department after experiencing a fainting episode. He reports feeling fatigued and nauseous. The patient has a medical history of type 2 diabetes mellitus and HIV infection, but admits to being non-compliant with his medications, including anti-retroviral therapy.

Upon examination, the patient’s pulse is regular at 65 beats per minute, blood pressure is 90/62 mmHg, and respiratory rate is 26 breaths per minute.

The following investigations were conducted:
– Haemoglobin: 14.0 g/dL (13.0-18.0)
– White cell count: 4 x 10^9/L (4-11)
– Platelets: 150 x 10^9/L (150-400)
– Sodium: 130 mmol/L (135-145)
– Potassium: 5.8 mmol/L (3.5-5.0)
– Creatinine: 80µmol/L (60-110)
– Glucose: 4.0 mmol/L (4.0-7.8)

What is the most appropriate next step in management?

MRCP2-1246

You are requested to evaluate a 43-year-old alcoholic who has been admitted to the medical ward after experiencing 72 hours of vomiting, generalized muscle weakness, and palpitations. Despite receiving two calcium infusions, the latest calcium measurement is still 1.89 mmol/l. During the examination, his blood pressure is 95/60 mmHg, and his pulse is regular at 95 beats per minute. You observe intermittent runs of SVT on his cardiac monitor.

The following are the other urea and electrolyte levels:

Na+ 132 mmol/l
K+ 3.7 mmol/l
Urea 5.4 mmol/l
Creatinine 82 µmol/l
Glucose 5.2 mmol/l

What is the most appropriate next step?

MRCP2-1247

A 50-year-old woman with chronic alcohol abuse admitted 4 days ago for nausea and severe diarrhoea now presents with peri-oral and finger tingling. She was admitted for hydration after 1 week of severe watery diarrhoea. Despite receiving intravenous hydration and dextrose, she has been unable to tolerate oral nutrition due to persistent nausea. Her vital signs are stable with a blood pressure of 130/74 mmHg, pulse of 68/min, and respiratory rate of 16/min. She has no fever.

During physical examination, the patient exhibits facial twitching upon percussion of her facial nerve just anterior to the ear. Additionally, carpal spasm is induced after the inflation of a blood pressure cuff on her arm.

What is the most likely cause of these findings?

MRCP2-1248

You are requested to assess a 68-year-old male who is currently admitted to a surgical ward with new onset paraesthesia in his fingers. He underwent an elective parathyroidectomy three days ago for long-standing hyperparathyroidism and subsequent hypercalcaemia. The surgery involved the removal of a single parathyroid adenoma which was identified on pre-operative MIBI scanning. Although the procedure was uneventful, he is now experiencing a tingling sensation in his fingers which he first noticed about twelve hours ago. Additionally, he complains of severe pain in both ankles which worsens with walking and is also present at rest. The surgical SHO has already arranged for ankle x-rays which reveal multiple osteolytic lesions that are suspicious for metastatic disease. Apart from regular prophylactic dalteparin, paracetamol, and tramadol, he is otherwise healthy. The following are his blood test results:

Adjusted Calcium 1.84 mmol/L
Magnesium 0.7 mmol/L

What is the most probable cause of his current symptoms?

MRCP2-1249

A 67-year-old Indian patient presents to the emergency department with facial tetany, muscle cramps and paraesthesia of her fingers and toes. This is her third admission with similar symptoms. Her past medical history includes diffuse cutaneous systemic sclerosis with gastrointestinal, cutaneous and pulmonary manifestations. She was also diagnosed with vitamin D deficiency three years ago and receives regular vitamin D supplements.

Her blood tests are as follows:

Hb 124 g/l
WBC 8.0 * 109/l
Na+ 141 mmol/l
K+ 4.3 mmol/l
Urea 6.5 mmol/l
Creatinine 90 µmol/l
CRP 15 mg/l
Corrected calcium 1.68 mmol/l
Phosphate 1.4 mmol/l
Magnesium 0.28 mmol/l
PTH 2 pmol/L (normal range = 8.5-12)
Amylase 14 u/l

Her symptoms improve with intravenous calcium replacement and intravenous magnesium replacement, correcting both electrolytes to within normal range. What is the underlying cause for these metabolic disturbances in this patient?

MRCP2-1250

A 58-year-old male presents with impotence. He was diagnosed with diabetes mellitus 8 years ago and has been taking metformin for the last 2 years. He has noticed a decline in his erectile function over the last year and is now completely impotent. He is a non-smoker and drinks approximately 8 units of alcohol per week.

On examination, he is obese with a blood pressure of 150/90 mmHg. Testicular examination reveals normal testes of approximately 18 ml in volume. There are no abnormalities on cardiovascular, respiratory or abdominal examinations.

Investigations reveal:
– Haemoglobin: 140 g/L (130-180)
– White cell count: 8.5 ×109/L (4-11)
– Platelets: 190 ×109/L (150-400)
– Serum sodium: 143 mmol/L (137-144)
– Serum potassium: 4.2 mmol/L (3.5-4.9)
– Serum urea: 6.8 mmol/L (2.5-7.5)
– Serum creatinine: 105 µmol/L (60-110)
– Serum alkaline phosphatase: 90 U/L (45-105)
– Serum aspartate aminotransferase: 28 U/L (1-31)
– Serum gamma GT: 40 U/L (<50)
– HbA1c: 7.5% (3.8-6.4)
– Fasting plasma glucose: 8.0 mmol/L (3.0-6.0)
– Plasma testosterone: 6.8 nmol/L (9-33)
– Plasma FSH: 3.9 mU/L (3-12)
– Plasma luteinising hormone: 4.9 mU/L (3-10)

What further investigation would you recommend for this patient?

MRCP2-1215

A 50-year-old man visits his GP for a routine check-up of his type 2 diabetes, which he manages with metformin. He recently had an NSTEMI and is now taking aspirin, clopidogrel, bisoprolol, and ramipril.

Blood tests taken 6 months ago showed:

– HbA1c of 51 mmol/mol (<48) Today’s blood tests show: – HbA1c of 47 mmol/mol (<48) What is the appropriate course of action for managing this patient’s type 2 diabetes at this stage?

MRCP2-1216

A 49-year-old man comes for a diabetes check-up after being prescribed metformin 500mg TDS. His latest HbA1c reading is 48 mmol/mol and he has not experienced any hypoglycaemic episodes.

The patient has a medical history of atrial fibrillation and heart failure with preserved ejection fraction. He is currently taking apixaban, bisoprolol, atorvastatin, and ramipril.

What would be the most suitable course of action for managing his diabetes?