Archives: MRCP Part 2

MRCP2-1182

A 42-year-old man comes to the endocrinology clinic for his annual review of type 1 diabetes mellitus. He was diagnosed with diabetes after being admitted with diabetic ketoacidosis (DKA) at the age of 21. He has been managing his diabetes with a basal-bolus regimen of insulin. He had one admission with DKA in the year following his diagnosis due to excessive alcohol intake, but has since significantly reduced his alcohol consumption. His retinal photography was normal 11 months ago. His blood pressure is 135/81 mmHg, and his blood tests show normal cholesterol levels and an HbA1c of 42 mmol/mol. He provided a urine sample today to measure the albumin to creatinine ratio, but dipstick testing showed no protein in the sample. What is the most appropriate medication adjustment to make?

MRCP2-1183

A 26-year-old woman presents to the emergency department with vomiting and feeling dizzy. She has a medical history of Addison’s disease, hypothyroidism, and vitiligo. Due to nausea and vomiting, she has been unable to take her normal dose of hydrocortisone and fludrocortisone for the past five days. Her usual medication includes hydrocortisone 10mg, 10mg, and 5mg at morning, lunchtime, and afternoon, fludrocortisone 100 micrograms, and levothyroxine 100 micrograms.

The patient has received 100mg of IV hydrocortisone, 2L of IV fluids, and 10mg of metoclopramide IV, which has helped settle her nausea. However, she is still struggling to eat or drink, and her systolic blood pressure has increased from 82 mmHg to 110 mmHg. Her capillary glucose is 8.5 mmol/l. The medical team has prescribed regular IV hydrocortisone and anti-emetics.

What additional prescription would be appropriate for this patient at this stage?

MRCP2-1184

A 23-year-old woman is referred to the clinic by her GP. She has been concerned about her recent weight gain of 4 kg over the past 3 months and has not had a period for the past 2 months. There is also some breast tenderness and a feeling of fullness.. On examination, she appears healthy with a normal blood pressure of 120/80 mmHg and all other features are within normal limits.

Investigations:

Haemoglobin 145 g/l 130–170 g/l
White cell count (WCC) 6.2 × 109/l 4–11 × 109/l
Platelets 180 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine 80 µmol/l 50–120 µmol/l
Prolactin 1600 mU/l < 400 mU/l What is the most likely diagnosis?

MRCP2-1185

A 28-year-old woman presents to the outpatient department with symptoms of heat intolerance, diarrhoea, and anxiety that have been increasing over the past few weeks. She is currently 32 weeks pregnant with her first child and has a medical history of hyperthyroidism, which is being treated with 10 mg carbimazole. Her mother also had hyperthyroidism. The patient does not smoke, drink alcohol, or use recreational drugs.

During the examination, her pulse is 98 beats per minute, blood pressure is 124/82 mmHg, and respiratory rate is 14/min. Her oxygen saturation is 98%, and temperature is 37.5ºC.

Blood tests reveal the following results:

Thyroid stimulating hormone (TSH) 0.04 mu/l
Free thyroxine (T4) 21 pmol/l
Total thyroxine (T4) 152 nmol/l

What is the most appropriate course of management?

MRCP2-1186

A 32-year-old woman is seen in your pre-natal endocrinology clinic. She has been on a daily dose of 100 micrograms of levothyroxine for hypothyroidism and is currently 8 weeks pregnant. Her TSH level is 5.0 mU/L (0.5-5.5) and her free T4 level is 10.0 pmol/L (9.0 – 18). What adjustments would you suggest for her levothyroxine dosage?

MRCP2-1187

A 29-year-old pregnant woman presents to the Emergency Department with symptoms of palpitations and sweating. She reports experiencing these symptoms intermittently for the past 5 months, but they have become more severe in recent weeks. She appears anxious and concerned about the possibility of a miscarriage. This is her first pregnancy, and she has not experienced any vaginal bleeding or discharge. She is otherwise healthy and physically active.

Upon initial assessment, her blood pressure is 130/85 mmHg, heart rate is 110 beats per minute, respiratory rate is 19/min, oxygen saturation is 99% on air, and temperature is 37.5ºC. A resting tachycardia and subtle goitre are noted during examination.

Blood test results show:

– Hb: 110 g/l
– Wcc: 12 x109/l
– Plt: 245 x109/l
– CRP: 12 mg/l
– Na+: 140 mmol/l
– K+: 5.0 mmol/l
– Ur: 5.7 mmol/l
– Cr: 110 µmol/l
– D-dimer: 490 ng/ml
– T4: 21 mU/l
– TSH: <0.05 pmol/l Based on the likely diagnosis, what is the appropriate management plan for this patient?

MRCP2-1188

A 29-year-old female patient presents with a 6 month history of weight loss (despite an increase in appetite), tremors, loose bowels, and heat intolerance. She has been in good health otherwise, and her only significant family history is that her sister has alopecia areata. The patient reports a positive pregnancy test last week and is waiting for her booking appointment. During examination, the patient appears anxious, and her heart rate is 105 beats/minute. She has a tremor when her arms are outstretched, and her eyes appear large. Additionally, she has a goitre. Blood tests reveal hyperthyroidism. Which medication is the most appropriate for treating her hyperthyroidism?

MRCP2-1189

A 58-year-old male presents with weight loss, weakness, and increasing confusion. He was diagnosed with small cell carcinoma of the lung eight months ago and has undergone chemotherapy.

On examination, he is disorientated in time and place, has evidence of weight loss, and a BMI of 22.6 kg/m2. His blood pressure is 160/98 mmHg with a pulse of 88 bpm. He has weakness of leg extension and has difficulty rising from a seated position. He also has shoulder weakness.

Baseline investigations reveal:
– Haemoglobin 165 g/L (130-180)
– Sodium 152 mmol/L (134-144)
– Potassium 2.8 mmol/L (3.5-5.5)
– Urea 9.5 mmol/L (3-8)
– Creatinine 158 µmol/L (50-100)
– Glucose 14.1 mmol/L (3.5-6)
– CPK 280 mU/L (100-250)

What is the most likely diagnosis?

MRCP2-1190

A 49-year-old woman visits her GP complaining of hot flushes and night sweats for the past few weeks. She also mentions difficulty concentrating and disturbed sleep at night. Her husband reports mood swings. On examination, her blood pressure is 122/78 mmHg, heart rate is 78 bpm, and BMI is 23 kg/m2. Abdominal examination is normal. She is prescribed hormone replacement therapy and asks about its benefits. What is associated with hormone replacement therapy?

MRCP2-1191

A 25-year-old woman presents with a history of weight gain and amenorrhoea for the past four months. Upon examination, she has a BMI of 33 and mild hirsutism. Her test results show a serum oestradiol level of 1200 pmol/L (130-800), serum testosterone level of 2.8 nmol/L (<3.0), serum prolactin level of 1500 mU/L (50-450), serum LH level of 1.2 U/L (1.2-8.0), and serum FSH level of 1.5 U/L (1.5-8.0). What is the most likely diagnosis?