Archives: MRCP Part 2

MRCP2-1176

A 23-year-old male patient presents to his family doctor with concerns about delayed puberty. He has difficulty forming romantic relationships and feels that things always fall apart when things become physical. Upon examination, he has minimal body hair and an underdeveloped penis with small testicles. His blood pressure and body mass index are within normal limits. He also reports a loss of sense of smell. The following investigations were conducted:

Testosterone: 6 nmol/L (normal range: 9-35 nmol/L)
Follicle-stimulating hormone (FSH): 0.8 U/L (normal range: 1-25 U/L)
Luteinizing hormone (LH): 0.6 U/L (normal range: 1-70 U/L)
Thyroid-stimulating hormone (TSH): 1.1 µU/L (normal range: 0.17-3.2 µU/L)

What is the most likely diagnosis based on this clinical presentation?

MRCP2-1177

You are asked to review an 83-year-old woman on the care of the elderly ward as serum sodium results are low. The patient was admitted six hours ago with a diagnosis of community-acquired pneumonia and exacerbation of congestive cardiac failure. She presented with a productive cough, shortness of breath and leg swelling. She has a past medical history of multiple myocardial infarcts five years ago and has subsequently developed heart failure. She also has had osteoarthritis, hypertension and high cholesterol. She takes aspirin, ramipril, furosemide, bisoprolol, omeprazole and atorvastatin. On examination, she has a raised JVP and bilateral crepitations to midzones bilaterally as well as oedema to the sacrum.

Blood tests:
Hb 120 g/l
Platelets 480 * 109/l
WBC 14.2 * 109/l
Na+ 126 mmol/l
K+ 3.5 mmol/l
Urea 6.3 mmol/l
Creatinine 84 µmol/l

Urinary sodium: 16 mmol/l

What is the most likely cause of hyponatraemia?

MRCP2-1139

A 45-year-old male presents with a six month history of fatigue, weight gain, and difficulty concentrating. He had surgery two years ago for a non-functional pituitary tumor and has been on replacement therapy with hydrocortisone, thyroxine, and testosterone. His lab results show low TSH and IGF-1 levels, but normal testosterone and free T4 levels. What treatment option would be most effective in improving this patient’s symptoms?

MRCP2-1140

A 28-year-old female patient, who has a history of schizophrenia, presents to the Emergency Department with complaints of nausea and lethargy. Upon examination, the patient appears to be clinically euvolaemic with a Glasgow Coma Score (GCS) of 14. No focal neurological signs are observed. The patient’s serum sodium concentration is found to be 114 mmol/L, and there is no history of seizure activity. What is the most suitable course of action to correct the patient’s abnormal biochemistry?

MRCP2-1141

A 19-year-old male presents with a two day history of vomiting, general lethargy and dizziness.

Over the last six months he had lost 5 kg in weight, had a reduced appetite and had been feeling increasingly lethargic. He had no past medical history of note, was a non-smoker and did not take any regular medications. His elder brother was well and there was no significant family history.

On examination, he was comfortable at rest, appeared slightly dehydrated, was apyrexial, had a body mass index of 19 kg/m2 and oxygen saturations on air of 98%. His blood pressure was 110/70 mmHg and fell to 90/60 mmHg on standing. His pulse was 80 beats per minute regular and auscultation of the heart and chest were normal. No abnormalities were detected on abdominal or CNS examination.

Investigations revealed:

– Haemoglobin 110 g/L (130-180)
– Mean cell volume 90 fL (80-100)
– White cell count 9.2 ×109/L (4-11)
– Neutrophils 5.0 ×109/L (1.5-7)
– Lymphocytes 3.2 ×109/L (1.5-4)
– Eosinophils 0.6 ×109/L (0.04-0.4)
– Serum sodium 132 mmol/L (135-145)
– Serum potassium 5.5 mmol/L (3.5-5.1)
– Serum urea 10.2 mmol/L (2.5-7.5)
– Serum creatinine 120 µmol/L (60-110)
– Plasma glucose 4.2 mmol/L (3.0-6.0)
– Free T4 12.0 pmol/L (10-22)
– TSH 1.0 mu/L (0.4-5)
– Urinalysis Ketones +

Which of the following is the most appropriate investigation for this patient?

MRCP2-1142

A 16-year-old girl from a traveller family presents to the clinic with concerns about her pubertal development. She has not yet experienced any secondary sexual hair growth or started her periods. As an infant, she underwent surgery to repair bilateral inguinal hernias. On examination, her height is 167 cm, blood pressure is 122/72 mmHg, and BMI is 21. Breast development appears normal, but there is no pubic or axillary hair. Laboratory tests reveal a hemoglobin level of 124 g/L, white blood cell count of 8.0 ×109/L, platelet count of 180 ×109/L, sodium level of 137 mmol/L, potassium level of 4.4 mmol/L, and creatinine level of 110 µmol/L. Based on this information, what is the most likely diagnosis?

MRCP2-1143

A 14-year-old female presents with primary amenorrhoea.

She is accompanied by her mother who explains that she has also lost approximately 10 kg of weight over the last year and has occasional episodes of diarrhoea. She has recently become a vegetarian and tends to favour wheat snacks and bread.

Her progress at school has been excellent, she plays the piano in the school orchestra and she regularly goes jogging several times a day. She has a younger brother who is well and her mother and maternal aunt have a past history of hyperthyroidism. Her parents divorced about two years ago and she sees her father infrequently. She takes no medication.

On examination she is thin with a BMI of 16.6 kg/m2 and appears phenotypically female. She has normal breast development with no galactorrhoea to expression, has absence of axillary and scanty pubic hair.

Investigations reveal the following:

Plasma oestradiol 70 pmol/L (130-550)

LH 3.5 mU/L (2-10)

FSH 4.0 mU/L (2-10)

17 Hydroxyprogesterone 5.2 nmol/L (3-15)

Free T4 12.4 pmol/L (10-22)

TSH 2.2 mU/L (0.4-5)

Prolactin 520 mU/L (50-500)

What is the most likely diagnosis?

MRCP2-1144

A 22-year-old female student presents with symptoms of weight gain and depression. She started university six months ago and three months ago sought treatment for worsening facial acne. Although topical tetracycline improved her acne, she has since become increasingly depressed, struggles with coursework, and experiences physical difficulty getting out of bed in the mornings. She has also noticed a weight gain of approximately 5 kg and menstrual irregularity. On examination, she has mild facial acne, a blood pressure of 128/86 mmHg, and a BMI of 32.1 kg/m2. Laboratory investigations reveal normal full blood count and electrolytes, a glucose level of 5.6 mmol/L (3.0-6.0), oestradiol level of 100 pmol/L (>130), LH level of 8.4 (1-10), and FSH level of 3.4 (1-10). What is the most appropriate next step in managing this patient?

MRCP2-1145

A 36-year-old female presents with a 2-year history of weight gain, hirsutism, and hypertension. She has also experienced irregular periods over the last 2 years and has not had a period in the last 2 months. On examination, she has a BMI of 32.4, a reddish complexion, abdominal striae, and difficulty rising from a squatting position. Her blood pressure is 168/98 mmHg.

The following investigations were conducted:
– U+E: Normal
– FBC: Normal
– Plasma glucose: 12.1 mmol/L (3.0-6.0)
– Thyroxine: 12.4 pmol/L (10-22)
– TSH: 0.85 mU/L (0.4-5)
– Oestradiol: <80 pmol/L (130-510)
– LH: 4.2 mU/L (2-10)
– FSH: 2.1 mU/L (2-10)
– 9 am Cortisol: 550 nmol/L (200-550)
– ACTH (morning): 45 (8-50)
– Midnight Cortisol: 420 nmol/L (<180)
– ACTH (evening): 35 (8-20)
– 24 hr Urine free cortisol: 580 nmol/d (90-290)
– Chest x Ray: Normal
– ECG: LVH
– Cortisol at end of low dose dexamethasone test (48 hrs 0.5 mg qds): 210 nmol/L
– Cortisol at end of high dose dexamethasone test (48 hrs 2 mg qds): 150 nmol/L
– MRI of pituitary: Normal

Which of the following apply to this patient?

MRCP2-1146

A 50-year-old male with diabetes presented at the diabetic clinic for his annual review. He had been diagnosed with diabetes eight years ago and had been attending clinic regularly. He was also receiving treatment for hypertension and was taking metformin 500 mg tds, gliclazide 80 mg daily, atorvastatin 10 mg/d, ramipril 10 mg/d and bendroflumethiazide 2.5 mg/d. On physical examination, he was found to be obese, weighing 130 kg, and had striae in the abdomen.

Further investigations revealed that his HbA1c was 65 mmol/mol (20-46) or 8.1% (3.8-6.4) and his fasting glucose was 9 mmol/L (3.0-6.0). His 24-hour urine free cortisol was 354 mmol/day (<250) and his 9am plasma ACTH was 4 ng/dL (10-50). A CT scan of his abdomen showed a 3 cm right adrenal mass. What is the nature of the adrenal mass?