Archives: MRCP Part 2

MRCP2-1166

A 25-year-old woman presents with worsening hirsutism and is referred by her primary care physician. She has noticed increased facial and truncal hair growth since she began menstruating at age 15. She had been taking oral contraceptives and had regular periods until she stopped due to weight gain a year ago. She has only had one period in the past three months.

During the examination, her pulse was 82 beats per minute, blood pressure was 128/82 mmHg, and her BMI was 30.4 kg/m2. The following laboratory results were obtained: Free T4 12.8 pmol/L (10-22), TSH 1.2 mU/L (0.4-5), 17 Beta-oestradiol 254 pmol/L (130-850), LH 11.4 mU/L (2-10), FSH 6.2 mU/L (2-10), Prolactin 610 mU/L (50-450), Testosterone 3.2 nmol/L (<3), Dehydroepiandrostenedione sulphate (DHEAS) 17.2 pmol/L (2-10), and 17-Hydroxyprogesterone 3.2 pmol/L (2-20). What is the most likely diagnosis?

MRCP2-1167

A 72-year-old man who has been on long term digoxin therapy presents to the clinic with complaints of palpitations at rest. During examination, his blood pressure is 140/80 mmHg and his resting pulse is 95/min. Thyroid gland examination is unremarkable. Further investigations reveal the following results:

– Haemoglobin (Hb): 122 g/l (normal range: 115-155 g/l)
– White cell count (WCC): 5.8 × 109/l (normal range: 4.0-11.0 × 109/l)
– Platelets (PLT): 175 × 109/l (normal range: 150-400 ×109/l)
– Sodium (Na+): 140 mmol/l (normal range: 135-145 mmol/l)
– Potassium (K+): 4.5 mmol/l (normal range: 3.5-5.0 mmol/l)
– Creatinine (Cr): 128 μmol/l (normal range: 50-120 μmol/l)
– Thyroid-stimulating hormone (TSH): 0.4 U/l (normal range: 0.5-4.5 U/l)
– Thyroid autoantibodies: Negative
– Interleukin 6 (IL-6): Elevated

You decide to switch his digoxin to another medication. What is the primary treatment approach in this scenario?

MRCP2-1168

A 32-year-old woman who is 32 weeks’ pregnant presents to the clinic with complaints of increasing fatigue, mood swings, exhaustion particularly in the evenings, and episodes of heart palpitations. Her primary care physician has attributed these symptoms to the normal stresses and strains of pregnancy. Upon examination, she appears fatigued, her blood pressure is 126/80 mmHg, and her resting pulse is 92/min. You observe that she has sweaty palms and a small, smooth goiter upon palpation. The following investigations were conducted:

Haemoglobin (Hb) 112 g/l 115–155 g/l
White cell count (WCC) 5.8 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 178 × 109/l 150–400 × 109/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 98 µmol/l 50–120 µmol/l
Thyroid-stimulating hormone (TSH) < 0.05 µU/l 0.17–3.2 µU/l What is the most probable diagnosis?

MRCP2-1169

A 16-year-old boy visits his family doctor, concerned about his delayed puberty compared to his peers. He reports no other symptoms and has a clean medical history. Upon examination, he appears tall but lacks muscle development and facial hair. His testicles measure 4 cm2 on orchidometry, and there is minimal pubic hair growth. The following investigations were conducted:

Luteinising hormone (LH) 0.7 mIU/ml 1.3–8 mIU/ml
Testosterone 3 nmol/l 10–30 nmol/l

What is the most probable diagnosis?

MRCP2-1170

A 28-year-old man is referred to the Endocrinology Clinic by his primary care physician. He has had two episodes of fainting over the past three months. There is also a history of increased thirst and urination, which has been accompanied by gradual weight loss.

On further questioning, family history reveals no useful information. You elect to admit him for a period of fasting. The morning after admission, some 14 hours without food, he complains of feeling dizzy.

Investigations reveal the following:

Glucose 2.8 mmol/l < 7 mmol/l
Insulin 2 mU/l with decreased proportion of pro-insulin
C-peptide Decreased
Cortisol 400 nmol/l
9 am: 140–500 nmol/l
Midnight: 50–300 nmol/

Which of the following diagnoses fits best with this clinical picture?

MRCP2-1171

A 42-year-old woman with a lengthy history of Type 1 diabetes arrives at the Emergency Department with a sudden onset of diplopia. Despite basal bolus insulin, her diabetes is poorly controlled, and a recent HbA1c test showed a reading of 76 mmol/mol (9.1%). She has previously undergone laser therapy for diabetic retinopathy, experiences numbness in both feet, and has recovered from a left common peroneal nerve palsy. During the examination, her right eye is looking down and out, there is a ptosis on the right-hand side, and the pupil appears unaffected.
Investigations:
Hb 120 g/l
WCC 7.1 x109/l
PLT 201 x109/l
Na+ 137 mmol/l
K+ 5.0 mmol/l
Creatinine 132 micromol/l
Glucose 9.3 mmol/l
ESR 9 mm/1st hour
What is the most probable underlying cause of her cranial neuropathy?

MRCP2-1172

A 59-year-old woman with poorly controlled type II diabetes presents to the Emergency Department with burning pain and weakness in her left thigh after starting insulin therapy. She is not due for follow-up in clinic for two months. On examination, she has a blood pressure of 145/90 mmHg, and neurological findings reveal weakness and wasting of the left quadriceps, loss of the left knee jerk, and slightly diminished sensation over the medial aspect of the thigh. Her HbA1c is 64 mmol/mol (8.0%), and other investigations are within normal limits. Based on these findings, what is the most likely diagnosis?

MRCP2-1173

A 14-year-old girl comes to the Endocrine Clinic with her parents. They are concerned about her excessive weight gain. Apparently, she has gained a significant amount of weight in the past six months and her parents are unable to find clothes that fit her. She has no significant past medical history apart from asthma.
On examination, her blood pressure is 128/86 mmHg; pulse is 76 bpm and regular. She is 1.65 m tall and has a BMI of 32 (her parents have a BMI of 24 and 25). She has a round face, a buffalo hump, and appears to have excess hair growth. You note normal secondary sexual characteristics.
Investigations:

Haemoglobin (Hb) 138 g/l 135–175 g/l
White cell count (WCC) 6.2 × 109/l 4–11 × 109/l
Platelets (PLT) 240 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 80 µmol/l 50–120 µmol/l
Glucose 7.2 mmol/l (fasting) < 7 mmol/l
Cortisol 800 nmol/l (8 am) 171–536 nmol/l
Which of the following is the most likely diagnosis?

MRCP2-1174

A 48-year-old woman presented to the outpatient clinic with a four-week history of diarrhea and weight loss. She had no significant medical history and was not taking any regular medications. On examination, a smooth, diffusely enlarged mass was palpable over her trachea, which moved upwards on swallowing. Her pulse was regular at 100 beats per minute, and her blood pressure was 135/60 mmHg. Her abdomen was soft and non-tender with active bowel sounds, and a fine tremor was noted.

The following investigations were conducted:
– Serum sodium: 139 mmol/L (137-144)
– Serum potassium: 4.1 mmol/L (3.5-4.9)
– Serum urea: 3.2 mmol/L (2.5-7.5)
– Serum creatinine: 89 µmol/L (60-110)
– Plasma T4: 55 nmol/L (58-174)
– Plasma free T4: 9 pmol/L (10-22)
– Plasma TSH: <0.2 mU/L (0.4-5.0)
– Plasma thyroid binding globulin: 22 mg/L (13-28)
– Radioactive iodine uptake was found to be increased.

What is the most likely diagnosis?

MRCP2-1175

A 72-year-old woman who has been on long-term amiodarone therapy for paroxysmal AF presents to the clinic with complaints of increasing palpitations, weight loss, and heat intolerance over the past few months. During the examination, her blood pressure is 149/89 mmHg, pulse is 85 and regular, and she appears sweaty with a tremor. A TSH test reveals a measurement of 0.1 IU/L. What is the most effective way to differentiate between type 1 and type 2 Amiodarone-induced thyrotoxicosis (AIT)?