Archives: MRCP Part 2

MRCP2-1147

A 72-year-old man presented with general malaise and nausea. He was a retired farmer who had kept mostly sheep on his farm. He had returned from a holiday in Spain two weeks ago and had been feeling increasingly fatigued since then. He had also experienced poor appetite and an 8 kg weight loss over the past three months. He had a history of hypothyroidism and was taking thyroxine 100 mcg daily. He smoked five cigarettes per day and usually drank about 12 units of alcohol daily, but had consumed more alcohol than usual while on holiday. On examination, he appeared dehydrated, sun-tanned, and slightly confused, with a pulse of 92 bpm regular, a temperature of 37.2°C, and a blood pressure of 100/80 mmHg. His cardiovascular and respiratory examination were unremarkable, but he had a slight liver edge on palpation. Neurological examination was normal. Investigations revealed serum sodium of 125 mmol/L, serum potassium of 5.6 mmol/L, serum corrected calcium of 2.73 mmol/L, serum standard bicarbonate of 15 mmol/L, serum urea of 22 mmol/L, and plasma TSH of 6 mU/L. What is the most likely diagnosis?

MRCP2-1148

A 28-year-old female presents with a three month history of weight loss and general lethargy.

She has a five year history of Type 1 diabetes for which she has been treated with basal bolus insulin consisting of short acting insulin thrice daily and long acting insulin in the evenings.

Commensurate with her weight loss of 5 kg over the last three months she has noticed that she has recently encountered more hypoglycaemic events and has reduced her insulin requirements from 60 units per day to 38 units daily.

She takes no medication other than the oral contraceptive pill. She is a non-smoker and denies use of any illicit substances.

On examination she has a BMI of 21.2 kg/m2 and appears comfortable. Her pulse is 68 beats per minute regular and her blood pressure is 118/70 mmHg. There are no specific abnormalities of the chest, heart or abdomen but she has a slight purplish-yellow, non-tender 2-3 cm well circumscribed papules on both shins.

Investigations reveal:

Urinalysis Normal –
Haemglobin 12.1 g/dL (11.5-16.5)
White cell Count 5 ×109/L (4-11)
Random glucose 10.2 mmol/L (<11.1)
HbA1c 50 mmol/mol (20-46)
6.7% (3.8-6.4)
Plasma Sodium 135 mmol/L (137-144)
Plasma Potassium 4.5 mmol/L (3.5-4.9)
Plasma Urea 5 mmol/L (2.5-7.5)

What is the most appropriate investigation for this patient?

MRCP2-1149

A 25-year-old female presents with a two year history of secondary amenorrhoea and a six year history of facial hirsutism.

Examination reveals normal female secondary sexual characteristics with mild facial hair and hair extending up to the umbilicus and tops of thighs.

Investigations reveal:

Oestradiol concentration 65 pmol/L (130-450)

LH 3.2 mU/L (3-10)

FSH 3.5 mU/L (3-10)

Prolactin 320 mU/L (<450) Testosterone 3.4 pmol/L (<3) Which investigation from the following list may provide useful diagnostic information?

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?