Archives: MRCP Part 2

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?

MRCP2-1158

A 52-year-old woman presents to the Endocrinology Clinic with recently diagnosed type II diabetes. She reports leading a healthy lifestyle and is surprised by the diagnosis. Her past medical history includes hyperlipidemia, which is managed with atorvastatin.
On examination, her blood pressure is 140/80 mmHg and her heart rate is 72 bpm. Her cardiorespiratory examination is unremarkable, although she appears to be fatigued. Her abdomen is soft and non-tender. There is mild swelling of her ankles and she reports having to loosen her shoes due to discomfort.
Investigations:

Haemoglobin (Hb) 135 g/l 120 – 160 g/l
White cell count (WCC) 6.2 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 250 × 109/l 150 – 400 × 109/l
Sodium (Na+) 140 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 90 μmol/l 50 – 120 µmol/l
Random glucose 11.5 mmol/l 3.9 – 7.1 mmol/l

Which initial investigation would be most appropriate to confirm this patient’s likely underlying diagnosis?

MRCP2-1120

A 28-year-old woman, who has a 9-month-old baby, presents with neck and throat pain over the area of her thyroid. She tells you that she had a flu-like illness a week or so before the pain began. Her partner, who also attends the appointment, tells you she has been nervous and agitated over the past week. On examination, there is a mild diffuse enlargement of the thyroid gland and it is tender to palpation. Her BP is 141/82 mmHg, and her pulse is 85/min and regular at rest. She has a slight tremor.

Investigations reveal the following:
Haemoglobin (Hb) 121 g/l (normal values: 115–155 g/l)
White cell count (WCC) 6.1 × 109/l (normal values: 4.0–11.0 × 109/l)
Platelets (PLT) 170 × 109/l (normal values: 150–400 × 109/l)
Sodium (Na+) 139 mmol/l (normal values: 135–145 mmol/l)
Potassium (K+) 4.6 mmol/l (normal values: 3.5–5.0 mmol/l)
Creatinine (Cr) 100 μmol/l (normal values: 50–120 μmol/l)
Thyroid-stimulating hormone (TSH) <0.05 U/l
Anti-TPO Negative
Erythrocyte sedimentation rate (ESR) 62 mm/hour (normal values: 1–20 mm/hour)
fT4 24.3 pmol/l
Radioiodine uptake on the isotope scan is decreased.

Which of the following forms of thyroiditis is the most likely diagnosis?

MRCP2-1121

A 60-year-old man presents to hospital with a four day history of fatigue, muscle pains, a fever and pain in the front of his neck. Three weeks ago he had an upper respiratory tract infection which he treated himself with paracetamol and oral decongestants. He did not receive any antibiotics. His medical history is unremarkable except for occasional use of antihistamines during the summer.

During examination, he appears restless with a slight resting tremor. He has a temperature of 38.2°C, a pulse rate of 120 per minute which is regular and normal in character and a blood pressure of 130/80 mmHg. Heart sounds 1 and 2 were present with no added sounds and his chest was clear on auscultation. His abdomen was soft and non-tender with no organomegaly. Neurological examination was unremarkable apart from the slight resting tremor. Neck examination reveals a diffusely enlarged and tender thyroid gland.

Blood tests are requested and the results are as follows:

Hb 14.2 g/dl
Platelets 380 * 109/l
WBC 9.1 * 109/l
ESR (Westergren) 96 mm/1st hour Normal range 0-30
Free T4 210 nmol/l
Free T3 190 nmol/L
Plasma TSH <0.05 mU/l Which investigation is most likely to be useful in establishing the diagnosis?

MRCP2-1122

A 38-year-old woman comes to your clinic complaining of feeling warm and more anxious than usual. She had a cold three weeks ago. During the examination, you notice a new tender goitre.

You order blood tests, including thyroid function tests, which are shown in the table below.

Thyroid stimulating hormone (TSH) 0.2 mU/L (0.5-5.5)
Free thyroxine (T4) 25 pmol/L (9.0 – 18)

What thyroid scintigraphy results do you anticipate based on the probable underlying diagnosis?

MRCP2-1123

A 72-year-old man visits the falls clinic to discuss his osteoporosis medication. He has been taking weekly alendronate but is experiencing severe gastro-oesophageal reflux symptoms and has been hospitalized with coffee ground vomiting in the last three months. His recent DEXA scan shows a T score of -4.5 for the femoral neck. You decide to initiate denosumab treatment. What accurately describes the mechanism of action of denosumab?

MRCP2-1124

A 35-year-old woman presents with a two week history of feeling generally unwell, a 3 kg weight loss and suffering palpitations. She has otherwise been very well.

The only medication that she receives is an oral contraceptive. She is a non-smoker and drinks approximately 14 units of alcohol weekly. She is employed as an auxillary nurse and is single.

On examination she is apyrexial with a pulse of 98 beats per minute regular and a blood pressure of 124/80 mmHg and a BMI of 24.5 kg/m2. She has a slight tremor of the outstretched hands but no eye signs. She is noted to have a tender moderately enlarged goitre, with no audible bruit. No other abnormalities are noted.

Investigations reveal:

Full blood count Normal –

Urea and electrolytes Normal –

Glucose 5.5 mmol/L (3.0-6.0)

ESR 50 mm/hr (1-10)

Free thyroxine 27.9 pmol/L (10-22)

TSH 0.02 mU/L (0.4-5)

Thyroid peroxidase antibody Negative –

What is the most likely diagnosis?

MRCP2-1125

A 54-year-old man with a history of type 2 diabetes managed with Humalog mix 30 and metformin 1g BD presents for a check-up. His current HbA1c is 57 and he is experiencing troublesome hypoglycaemia episodes in the late afternoon and early mornings. What is the best course of action? On examination, his blood pressure is 132/82 mmHg, his pulse is regular at 72 beats per minute, and his BMI is 32 kg/m².

Investigations:

Na+ 139 mmol/l
K+ 4.9 mmol/l
Urea 5.1 mmol/l
Creatinine 94 µmol/l
HbA1c 57 mmol/mol

What is the most appropriate next step in his management?

MRCP2-1126

The following results were obtained on dual energy x ray absorptiometry (DEXA) scan of the spine of a 65-year-old Postmenopausal Caucasian female who was concerned about her bone health, due to a personal history of fractures.

BMD T score Z score
L1-L4 0.85 -1.2 (82%) +0.5 (110%)
L2-L4 0.87 -1.1 (83%) +0.6 (112%)
L1 0.83 -1.3 (81%) +0.4 (109%)

What do these results indicate?

MRCP2-1127

A 32-year-old patient is brought to the emergency department by ambulance with a decreased level of consciousness. She has a medical history of type 2 diabetes and emotionally unstable personality disorder. She takes metformin and gliclazide and smokes ten cigarettes daily. She is currently unemployed.

Upon examination, her heart rate is 111 beats per minute, blood pressure is 101/55 mmHg, respiratory rate is 21/minute, oxygen saturations are 96% on room air, and temperature is 37ºC. Her Glasgow coma scale is 9/15 (E1 V3 M5), and her neurological examination reveals normal tone and downgoing plantars. Her pupils are equal and reactive to light.

A bedside blood glucose level is measured at 1.8 mmol/L. Despite receiving 2 x 100ml boluses of 10% dextrose and subsequent dextrose infusion, the patient experiences recurrent hypoglycaemia.

What is the most appropriate pharmacological treatment to administer next?