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?

MRCP2-1150

A 50-year-old male presents with a one-year history of impotence and reduced shaving frequency. These symptoms have gradually developed over time and he has no libido or erections. He also shaves only once a week compared to his previous daily routine. In addition, he has been experiencing joint aches and lethargy with reduced energy levels. He has no medical history except for an appendicectomy at the age of 20, takes no medication, and is married with no children. He drinks 20 units of alcohol per week and smokes five cigarettes daily.

During examination, he appears slightly pigmented with gynaecomastia and fine skin with scant facial, pubic, and axillary hair. Testicular examination reveals a size of approximately 15 ml bilaterally with no masses felt. Cardiovascular, respiratory, and abdominal systems are normal, and there are no abnormalities noted on joint movements with a full range of motion.

The following investigations were conducted:
– Prolactin: 370 mU/L (50-450)
– Testosterone: 3.5 nmol/L (10-30)
– LH: 2.1 mU/L (2-10)
– FSH: 2 mU/L (2-10)
– Free T4: 12.8 pmol/L (10-22)
– TSH: 2.1 mU/L (0.4-5)

What is the most important investigation to determine the underlying diagnosis for this patient?

MRCP2-1151

A 25-year-old man presents to the Endocrinology Clinic with bilateral gynaecomastia. He reportedly had surgery as a child to correct bilateral undescended testes.

On examination, he is tall, with increased arm and leg length. He does have evidence of bilateral breast enlargement, with small testes bilaterally. Apparently, there have been problems with self-esteem and social anxiety at work, and he is now seeking medical advice.

What would be the most appropriate investigation in this case?

MRCP2-1152

A 29-year-old woman comes to you with a complaint of worsening coordination over the past three months. Upon examination, her blood pressure is 124/74 mmHg. The only notable findings are right-sided dysdiadokinesis with nystagmus and a tendency to fall to the right. Additionally, you observe several café-au-lait spots. Which of the following potential causes would NOT account for her lack of coordination?

MRCP2-1153

A 67-year-old woman presents with a two-month history of increasing thirst, fatigue, and weight loss. She had breast cancer ten years ago and underwent a mastectomy, and has been taking tamoxifen since then. She also has a three-year history of hypertension and takes bendroflumethiazide 2.5 mg daily. On examination, her blood pressure is 162/90 mmHg, but no other abnormalities are found. She takes a large number of vitamins every day. Her general practitioner orders a series of biochemical tests, which reveal hypercalcemia. What is the most likely cause of her elevated calcium levels?

MRCP2-1154

A 60-year-old female presents with a three month history of generalised aches and pains.

These problems began rather gradually and she has noticed less energy of late. She has otherwise been in good health but has a five year history of hypertension for which she is treated with bendroflumethiazide 2.5 mg daily and more recently she has received lisinopril 5 mg daily. She has received regular blood pressure checks at her GP’s clinic. Over the last one year she has also been taking vitamin D supplements as she has been concerned regarding osteoporosis. She stopped taking female HRT approximately five years ago.

Of relevance in her family history was a strong maternal history of osteoporosis. Her mother had a fractured neck of femur at the age of 70 and her maternal aunts had problems with osteoporosis. She is a smoker of 15 pack years having stopped smoking five years ago. She drinks approximately 12 units of alcohol weekly.

On examination she is slightly built with a BMI of 22.2 kg/m2 and has a blood pressure of 152/84 mmHg. No specific abnormalities are noted on cardiovascular, respiratory or abdominal examination.

Investigations reveal:

Full blood count normal.

ESR 28mm/hr (1-10)

Sodium 133 mmol/L (137-144)

Potassium 3.3 mmol/L (3.5-4.9)

Urea 8.8 mmol/L (2.5-7.5)

Creatinine 92 µmol/L (60-110)

Calcium 2.72 mmol/L (2.2-2.6)

Phosphate 0.8 mmol/L (0.8-1.4)

Free T4 17.8 pmol/L (10-22)

TSH 0.3 mU/L (0.5-4.0)

PTH 4 pmol/L (0.9-5.4)

Urinalysis Normal

Chest x ray Nil reported

What is the most likely cause of this person’s hypercalcemia?

MRCP2-1155

A 32-year-old male presents with fatigue and unintentional weight loss. Four years ago he was diagnosed with type 2 diabetes mellitus (T2DM) and has been managing it with metformin. However, over the last year, his blood sugar levels have been difficult to control and he has experienced several episodes of hypoglycemia. He has also noticed a decrease in his libido and erectile dysfunction.
Examination reveals a thin male (BMI 20) with a pulse of 80 beats per minute and a blood pressure of 120/80 mmHg. Cardiovascular, respiratory and abdominal examination were normal. Sensation was intact and fundal examination is normal.
Investigations reveal:
Serum sodium 135 mmol/L (137-144)
Serum potassium 4.0 mmol/L (3.5-4.9)
Serum urea 6.5 mmol/L (2.5-7.5)
Serum creatinine 90 µmol/L (60-110)
Serum glucose 8.5 mmol/L (3.0-6.0)
HbA1c 70 mmol/mol (20-42)
8.6% (3.8-6.4)
Serum calcium 2.4 mmol/L (2.2-2.6)
Serum phosphate 1.2 mmol/L (0.8-1.4)
Serum free T4 12.0 pmol/L (10-22)
Serum TSH 2.5 mU/L (0.4-5.0)
Serum testosterone 8.0 nmol/L (9.9-27.8)
Which of the following is the most appropriate investigation for this patient?

MRCP2-1156

A 25-year-old man presents with mild breast tenderness, weight loss and anxiety. He is known to have Klinefelter syndrome and had an undescended testis for which he underwent orchidopexy as a child. He has no other past medical history of note. On examination, his blood pressure (BP) is 120/70 mmHg, his body mass index (BMI) is 20, he has gynaecomastia and small testes, his left appears more swollen than the right, but he tells you this is the one he had the operation on.

Investigations:
– Haemoglobin (Hb): 130 g/l (135-175 g/l)
– White cell count (WCC): 17.2 x 10^9/l (4-11 x 10^9/l)
– Platelet (PLT): 250 x 10^9/l (150-400 x 10^9/l)
– Sodium (Na+): 142 mmol/l (135-145 mmol/l)
– Potassium (K+): 4.2 mmol/l (3.5-5.0 mmol/l)
– Creatinine: 70 µmol/l (50-120 µmol/l)
– Beta human chorionic gonadotropin (B-HCG) 9000 U/l < 5 U/l
– Thyroid-stimulating hormone (TSH) < 0.05 µU/l 0.17–3.2 µU/l Which of the following is the next most appropriate investigation?

MRCP2-1157

A 29-year-old woman presents to the Endocrinology Clinic for review. She recently suffered a fall whilst at dancing and was knocked out for a few minutes.
Since then, over the past few weeks, she has suffered polyuria and polydipsia. She has no past medical history of note, and her only medication is the oral contraceptive pill.
On examination, her BP is 125/72 mmHg, with pulse 83/min and regular. She has a postural drop of 15 mmHg on standing. Her BMI is 21. Neurological assessment is unremarkable.
Investigations:
Investigation Result Normal values
Haemoglobin (Hb) 131 g/l 135 – 175 g/l
White cell count (WCC) 8.1 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 191 × 109/l 150 – 400 × 109/l
Sodium (Na+) 146 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.4 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 142 µmol/l 50 – 120 µmol/l
Urea 9.1 mmol/l 2.5 – 6.5 mmol/l
Glucose 5.4 mmol/l 3.9 – 7.1 mmol/l
Corrected calcium (Ca2+) 2.21 mmol/l 2.2 – 2.7 mmol/l
Which of the following is the most appropriate next investigation?