Archives: MRCP Part 2

MRCP2-1088

A 49-year-old man presents to the clinic with complaints of fatigue and weakness. He has a history of alcoholism and currently consumes 90 units of beer per week. He is taking regular thiamine and appears to be euvolaemic on examination.

The following are his blood test results:

– Hemoglobin (Hb): 122 g/l
– Platelets: 385 * 109/l
– White blood cells (WBC): 8.5 * 109/l
– Neutrophils (Neuts): 4.6 * 109/l
– Lymphocytes (Lymphs): 2.2 * 109/l
– C-reactive protein (CRP): 8 mg/l
– Sodium (Na+): 128 mmol/l
– Potassium (K+): 3.6 mmol/l
– Urea: 3.2 mmol/l
– Creatinine: 38 µmol/l

A paired serum and urine test shows:

– Serum osmolarity: 271 mOsm/kg (normal range 285-295)
– Urine osmolarity: 50 mOsm/kg (low)
– Urinary sodium: 8 mmol/l (low)

What is the most likely diagnosis?

MRCP2-1089

A 49-year-old female presents with recurrent palpitations, sweating, blurring of vision, and generalized weakness. She denies any chest pain, shortness of breath, or loss of consciousness. She has had several similar episodes over the past few months, usually occurring in the morning or just before a meal. Her symptoms improve after eating something. She has gained about 9 kg of weight over the last few months. She has a past history of an anxiety disorder but is not currently taking any regular medications. She does not smoke and only occasionally drinks alcohol. Her blood glucose at present is 4.9 mmol. Based on the history, what is the next step in evaluating this patient for insulinoma?

MRCP2-1090

A 56-year-old man comes to the clinic complaining of increased thirst and urinary frequency. He has a history of stable angina and is currently taking aspirin, atenolol, and atorvastatin.

Upon examination, no abnormalities are found.

Blood tests reveal an Hba1c level of 54 mmol/mol (<48). The patient is prescribed metformin 500mg twice daily. What is the next step in the pharmacological treatment of this patient given his current presentation?

MRCP2-1091

A 35-year-old man is admitted after being found at home covered in his vomit and excrement. He is a known alcoholic and has not been seen for three weeks.

On examination, he is drowsy and complaining of generalised aches and pains.

An ECG shows prolonged PR interval and prolonged QTc of 620ms.

On examination JVP is not visible, his mucous membranes are dry, and his eyes are sunken. His chest is clear, his heart sounds normal, and his abdomen soft and non-tender. There is moisture damage to his buttocks.

CT head is unremarkable.

Blood tests are completed and results are detailed below:

Hb 114 g/L Male: (135-180)
Female: (115 – 160)
Platelets 98 * 109/L (150 – 400)
WBC 10 * 109/L (4.0 – 11.0)

Na+ 131 mmol/L (135 – 145)
K+ 2.2 mmol/L (3.5 – 5.0)
Urea 14.2 mmol/L (2.0 – 7.0)
Creatinine 190 µmol/L (55 – 120)

Calcium 1.9 mmol/L (2.1-2.6)
Phosphate 0.6 mmol/L (0.8-1.4)
Magnesium 0.4 mmol/L (0.7-1.0)

What is the top priority in managing the electrolyte imbalances of this patient?

MRCP2-1092

A 67-year-old man with a history of diabetic nephropathy is referred to the rheumatology clinic after suffering a right Colles’ fracture. He is currently taking linagliptin for diabetes, as well as Ramipril and atorvastatin for hypertension and primary cardiovascular prevention.

During examination, his blood pressure is 140/80, pulse is 72 and regular, and BMI is 28. The cast has been removed from his wrist and there is minimal residual deformity. The doctor is considering starting him on bisphosphonate therapy. Routine blood tests show normal levels of calcium and phosphate, and an HbA1c of 56 mmol/mol (<53). What GFR level would be a contraindication for bisphosphonate therapy?

MRCP2-1093

A 35-year-old woman presents to her GP with a four-month history of weight loss and agitation. On examination, she has a fine tremor, a resting tachycardia, and a smooth goitre. Her lab results show elevated Free T4 and Free T3 levels and a suppressed TSH level. She is started on carbimazole and propranolol and returns a month later feeling better but with a three-day history of a sore throat. Her blood work shows a low hemoglobin level, low neutrophil count, and elevated lymphocyte count. What is the most appropriate management for this patient?

MRCP2-1094

A 49-year-old man with type 2 diabetes is on a twice daily pre-mixed insulin (NovoMix 30). He has come for a diabetic review at the clinic and has brought his recent blood sugar readings. He checks his blood sugar levels four times a day: before breakfast, before lunch, before dinner, and before bed. His pre-breakfast glucose readings range from 5.0 to 6.0 mmol/L, pre-lunch readings range from 8 to 11 mmol/L, pre-dinner readings range from 8 to 10 mmol/L, and pre-bed readings range from 6.0 to 8.0 mmol/L.

Which of the following statements is true in this case?

MRCP2-1095

A 36-year-old woman has a family history of multiple endocrine neoplasia type 2a and has tested positive for the RET oncogene. She is worried about developing thyroid cancer like her mother but is hesitant to undergo a prophylactic thyroidectomy. What other management options are available for her?

MRCP2-1096

A 49-year-old woman presents to clinic for follow-up after undergoing surgery to remove a medullary thyroid cancer. She had presented with a neck lump and diarrhea, and genetic testing revealed a RET oncogene mutation. The patient reports feeling well and there are no signs of local recurrence on examination.

What is the recommended test for monitoring potential recurrence?

MRCP2-1097

A 67-year-old man presents with a hot swollen right toe. Upon examination, there is swelling over the MTP joint of the right toe, reduced range of movement, and it is hot, swollen, and painful to touch. The patient has a history of alcohol excess and is not taking any regular medications. An aspirate of the joint fluid reveals negatively birefringent crystals that are needle-shaped. Due to the patient’s intolerance to NSAIDs and colchicine, a trial of prednisolone is initiated, but unfortunately, the patient develops steroid-induced psychosis. What alternative medication will be considered for this patient?