Archives: MRCP Part 2

MRCP2-1128

Which patient has results suggesting a diagnosis of diabetes insipidus?

Patient 1:
– Serum Na: 150 mmol/L
– Urine Na: 18
– Serum osmolality: 305 mOsm/kg
– Urine osmolality: 100
– TSH: 2.0 mIU/L
– 9am cortisol: 300 nmol/L

Patient 2:
– Serum Na: 136 mmol/L
– Urine Na: 35
– Serum osmolality: 275 mOsm/kg
– Urine osmolality: 160
– TSH: 12.5 mIU/L
– 9am cortisol: 450 nmol/L

Patient 3:
– Serum Na: 128 mmol/L
– Urine Na: 12
– Serum osmolality: 260 mOsm/kg
– Urine osmolality: 80
– TSH: 4.2 mIU/L
– 9am cortisol: 290 nmol/L

Patient 4:
– Serum Na: 128 mmol/L
– Urine Na: 50
– Serum osmolality: 258 mOsm/kg
– Urine osmolality: 150
– TSH: 2.0 mIU/L
– 9am cortisol: 485 nmol/L

Patient 5:
– Serum Na: 128 mmol/L
– Urine Na: 40
– Serum osmolality: 266 mOsm/kg
– Urine osmolality: 100
– TSH: 3.5 mIU/L
– 9am cortisol: 120 nmol/L

Answer: Patient 3 has results suggesting a diagnosis of diabetes insipidus.

MRCP2-1129

A 50-year-old man presented to the hospital complaining of severe pain in his thighs and buttocks, which made it difficult for him to walk. He had noticed increasing difficulty climbing stairs and rising from chairs over the past two months. The pain started gradually in his right leg and then spread to his left leg. The pain was not related to exertion and was now severe enough to keep him awake at night. He also reported feeling fatigued and had lost 8 kg in weight over the past six months despite having a good appetite.

The patient was diagnosed with diabetes two years ago but was an infrequent attender at his General Practitioner’s diabetic clinic. He claimed to adhere to his diabetic diet and continued to take the chlorpropamide prescribed from the clinic. He lived alone, smoked 20 cigarettes a day, and drank approximately 12 units of alcohol per week.

On examination, the patient appeared thin and uncomfortable. There was wasting of the quadriceps muscles bilaterally with loss of power (grade 3/5). Knee and ankle jerks could not be elicited, and both plantar responses were extensor. There was some loss of light touch and pinprick sensation over both feet and ankles.

Urinalysis revealed trace amounts of protein and glucose 1%. Based on these symptoms, what is the most likely diagnosis?

MRCP2-1130

A 20-year-old man is brought to the emergency department by ambulance. According to his mother, he has been experiencing loss of appetite and abdominal pain for the past two days, along with significant weight loss and fatigue over the past six months. The patient has no previous family history, but his older sister was recently diagnosed with pernicious anaemia.

Upon examination, the patient is found to be tachypnoeic and tachycardia with a central capillary refill time of six seconds. Abdominal examination reveals inconsistent tenderness without obvious signs of localised peritonism.

Initial investigations show abnormal results for urea, creatinine, sodium, potassium, fingerpick blood glucose, fingerpick blood ketones, and venous blood gas. Portable chest x-ray and electrocardiogram show no significant abnormalities.

What is the appropriate immediate management for this 20-year-old patient?

MRCP2-1131

A 20-year-old man presents to the emergency department with drowsiness and vomiting. He is accompanied by a friend who reports that he has been drinking heavily all day and has been vomiting for the past few hours.

Upon examination, the patient’s speech is slurred and confused. He responds to his name but pushes away in response to painful stimuli. His heart rate is 100 beats per minute and regular, blood pressure is 100/60 mmHg, capillary glucose is 18 mmol/L, and a urine dip shows pH: 4, blood: trace, ketones: +++, protein: trace, nitrites: negative and leukocytes: negative.

A chest x-ray shows no abnormalities. Venous blood gas results reveal a pH of 7.27 (7.35-7.45), bicarbonate of 10 mmol/L (22-26), base excess of -10 (-2 to +2), sodium of 135 mmol/L (137-144), potassium of 2.9 mmol/L (3.5-4.9), and chloride of 99 mmol/L (95-107). Serum glucose is 21 mmol/L.

What is the most crucial initial intervention?

MRCP2-1132

A 20-year-old with type 1 diabetes presents to the Emergency Department feeling unwell. She reports experiencing vomiting and diarrhoea for the past 2 days and has not been taking her full insulin doses due to loss of appetite. Her capillary glucose level is 37 mmol/l and urinalysis shows 4+ ketones.

Upon performing an arterial blood gas, the following results are obtained:

pH 7.12
pO2 13 kPa
pCO2 3.5 kPa
HCO3 13
Na 129 mmol/l
K 6.1 mmol/l

What is the most appropriate initial management for this patient?

MRCP2-1133

A 35-year-old male with a history of type one diabetes mellitus complains of abdominal pain and difficulty breathing. Upon examination, he is diagnosed with diabetic ketoacidosis. Which of the following tests would indicate the need for a conversation about potential admission to the intensive care unit?

MRCP2-1134

A 35-year-old man with a 20 year history of type 1 diabetes presents to the Emergency Department with complaints of nausea and vomiting for the past 48 hours. He has been taking canagliflozin to improve his overall glycaemic control and has reduced his insulin dose by 40%. On examination, he appears dehydrated and is mildly tender in the epigastrium. His vital signs are stable except for a temperature of 38.1°C. Laboratory investigations reveal elevated white blood cell count, low bicarbonate levels, and high lactate levels. What is the most likely diagnosis for this patient?

MRCP2-1135

A previously healthy 35-year-old male presents with a two month history of weight loss, fatigue, and nausea. Upon investigation, his lab results show a hemoglobin level of 105 g/L (130-180), MCV of 88 fL (80-96), white cell count of 6.0 ×109/L (4-11), platelets of 450 ×109/L (150-400), serum sodium of 130 mmol/L (137-144), serum potassium of 5.7 mmol/L (3.5-4.9), serum urea of 3.0 mmol/L (2.5-7.5), serum creatinine of 78 µmol/L (60-110), serum total T4 of 55 nmol/L (50-150), and serum TSH of 8 mU/L (0.4-5). What is the most useful diagnostic investigation in this case?

MRCP2-1136

A 50-year old woman has been diagnosed with type 2 diabetes and shows signs of possible cortisol excess, including striae, centripetal obesity, and proximal myopathy. Her initial lab results show elevated white cell count, AST, ALT, and alkaline phosphatase, as well as low potassium levels and high urine free cortisol and ACTH levels. An ultrasound reveals bulky adrenal glands, and a low dose dexamethasone suppression test confirms cortisol excess. A high dose dexamethasone suppression test and MRI of the pituitary gland are also performed. What is the next appropriate step for this patient?

MRCP2-1137

A 30-year-old female of Bangladeshi origin presents with a four-month history of weight loss and fatigue. She returned to the United Kingdom three months ago after spending a year in Bangladesh due to ill health. She has no significant medical history, is a non-smoker, has no alcohol intake, and has two children. On examination, she has a BMI of 20 kg/m2, pigmentation of the palmar creases and buccal mucosa, a pulse of 77 bpm, and a blood pressure of 100/62 mmHg. Laboratory investigations reveal low haemoglobin and MCV, elevated white cell count, and high ESR. Her 9am plasma cortisol level is also low. What would be the most appropriate investigation to establish the diagnosis in this patient?