Archives: MRCP Part 2

MRCP2-1056

A 14-year-old male presents to the clinic with complaints of steatorrhoea and poor growth. He has a family history of abetalipoproteinemia. The patient is not taking any regular medications. Upon examination, the patient exhibits ataxia and reduced visual acuity (6/12 in the right eye and 6/15 in the left eye).

The following investigations were conducted:

– Hb: 110 g/l
– Platelets: 380 * 109/l
– WBC: 10.1 * 109/l
– Neuts: 6.8 * 109/l
– Blood film: Acanthocytosis
– Na+: 136 mmol/l
– K+: 3.9 mmol/l
– Urea: 6.6 mmol/l
– Creatinine: 48 µmol/l

What management plan would you suggest for this patient?

MRCP2-1057

These thyroid function tests were obtained from a 60-year-old female who presents with fatigue. Past history includes hypertension and osteoporosis, for which she takes medication.

Free T4 23.5 pmol/L (10-22)
Free T3 2.8 pmol/L (5-10)
TSH 7.2 mU/L (0.4-5)

What is the most probable reason for these findings?

MRCP2-1058

You are seeing a 37-year-old woman with type 1 diabetes mellitus in your clinic. She is currently managing her diabetes with a basal-bolus regimen and takes citalopram 20mg od for depression. She was diagnosed with type 1 diabetes at the age of 13. Her recent blood work shows:

– Na+ 142 mmol/l
– K+ 3.9 mmol/l
– Urea 4.9 mmol/l
– Creatinine 79 µmol/l

– Total cholesterol 4.4 mmol/l
– HDL cholesterol 1.2 mmol/l
– LDL cholesterol 1.8 mmol/l
– Triglyceride 1.3 mmol/l

– Urine dip: No protein or blood

What would be the most appropriate approach to managing her lipid levels?

MRCP2-1059

A 55-year-old woman presents for follow-up in the general medical clinic. She was diagnosed with type 2 diabetes mellitus eight months ago after experiencing fatigue and polyuria. She has a history of hypothyroidism but no other medical conditions. Initially, she was prescribed metformin 500mg twice daily, but she had difficulty managing due to gastrointestinal side effects, including diarrhea. What would be the best course of action?

MRCP2-1060

A 38-year-old man presents to the Endocrine Clinic for a 6-month follow-up after surgery for a growth hormone secreting pituitary adenoma. He initially went to his primary care physician with changes in his facial appearance, soft tissue swelling affecting his hands and feet, and impaired glucose tolerance. His glucose metabolism has returned to normal.
During examination, his blood pressure is 150/80 mmHg, pulse is 72 bpm and regular, and BMI is 24 kg/m2.
Lab results show:
– Haemoglobin (Hb): 135 g/l (normal range: 115-155 g/l)
– White cell count (WCC): 6.5 × 109/l (normal range: 4-11 × 109/l)
– Platelets (PLT): 200 × 109/l (normal range: 150-400 × 109/l)
– Sodium (Na+): 138 mmol/l (normal range: 135-145 mmol/l)
– Potassium (K+): 4.2 mmol/l (normal range: 3.5-5.0 mmol/l)
– Creatinine (Cr): 85 µmol/l (normal range: 50-120 µmol/l)
– Glucose: 5.3 mmol/l (normal range: 3.9-7.1 mmol/l)
– Insulin-like growth factor (IGF-1): Just above the upper limit of normal
What is the most likely long-term consequence of acromegaly in this patient?

MRCP2-1061

A 57-year-old man presents to the GP clinic with facial changes that have developed over the past 6 months. He has a history of hypertension that remains uncontrolled despite adhering to medications, a low-salt diet, and regular exercise.

During his assessment, his vital signs are recorded as follows: temperature 36.7ºC, blood pressure 146/98 mmHg, heart rate 90/min, and respiratory rate 14/min. On examination, his facial features appear coarse and markedly different from his driver’s license photo taken 3 years ago. Additionally, his fingers are swollen, and his skin has thickened.

Further investigations reveal elevated IGF-1 levels and an MRI confirms the presence of a pituitary adenoma. The patient undergoes trans-sphenoidal surgery to remove the tumour.

However, on a follow-up visit 3 months later, his serum IGF-1 levels remain elevated, and he continues to experience the same symptoms as before. A repeat MRI shows no residual tumour.

What is the most appropriate next step in managing this patient?

MRCP2-1062

A 32-year-old woman presents to clinic with headaches and a fasting glucose level of 8.2 mmol/l. She has also noticed a change in her facial features and her shoe size has increased. On examination, she has enlarged hands and feet, as well as bitemporal hemianopia. Her blood pressure is elevated at 150/95 mmHg. An oral glucose tolerance test with growth hormone levels showed a blood glucose of 12.1 mmol/l at 120 min and failure to suppress growth hormone levels. An MRI scan of the pituitary fossa revealed an adenoma that was abutting the optic chiasm. The patient prefers medical therapy over surgery (transphenoidal resection of the adenoma). What is the most appropriate initial medical therapy for her?

MRCP2-1063

A 30-year-old woman presents to the emergency department with complaints of feeling unwell and experiencing shortness of breath. She has a medical history of type 1 diabetes mellitus and is known to be non-compliant with insulin therapy.

Upon examination, her vital signs are as follows: heart rate of 89 beats per minute, blood pressure of 111/77 mmHg, oxygen saturation of 96% on room air, respiratory rate of 24/minute, and a temperature of 37C.

A VBG reveals a pH of 7.05 (normal range: 7.35-7.45), lactate of 2.8 mmol/L (normal range: 0.0-2.0), HCO3- of 8 mmol/L (normal range: 22-26), K+ of 4.2 mmol/L (normal range: 3.5-5.5), Na+ of 128 mmol/L (normal range: 135-145), and glucose of 31 mmol/L (normal range: 4.0-7.8). Ketones are also present at 4.2 mmol/L (normal range: <0.6). The patient is started on IV fluids (IV 0.9% sodium chloride with added potassium) and a fixed rate insulin infusion. Four hours later, repeat investigations show improvement with a pH of 7.12, lactate of 2.2 mmol/L, HCO3- of 12 mmol/L, K+ of 4.6 mmol/L, Na+ of 131 mmol/L, glucose of 10 mmol/L, and blood ketones of 3.2 mmol/L. Based on the likely diagnosis, what is the most appropriate management choice at this point?

MRCP2-1064

A 76-year-old man with metastatic lung carcinoma presents with increasing lethargy and a number of falls. He describes feeling very unsteady on standing from his bed. His appetite has been poor and he has vomited two times each day for the past three days. There is no diarrhoea or abdominal pain and he denies any shortness of breath. He takes regular paracetamol for pain and omeprazole for dyspepsia.

On examination, he is a tanned gentleman with cachexia. He appears pale with dry mucosa and his abdomen is soft and non-tender. There is reduced air entry at the right base with bronchial breathing overlying. His heart sounds are normal and his capillary refill time is prolonged to 4 seconds. Bloods pressure is 85/65 mmHg, heart rate 86/min, respiratory rate 23/min

Hb 102 g/l Na+ 129 mmol/l
Platelets 189 * 109/l K+ 5.0 mmol/l
WBC 5.6* 109/l Urea 7.2 mmol/l
Neuts 4.2 * 109/l Creatinine 87 µmol/l
Lymphs 0.7 * 109/l CRP 32 mg/l
Eosin 0.1 * 109/l

CT-chest-abdomen-pelvis There is a 4cm mass in the right lower lobe with extension to adjacent pleura. Bilateral pleural effusions are present. There is mediastinal lymphadenopathy and enlargement of para-aortic nodes with masses seen in both adrenals. Findings are in keeping with a primary lung malignancy with metastatic spread

What is the most probable cause of this presentation?

MRCP2-1065

A 14-year-old boy is brought to the Emergency department by his parents. He has a two day history of general malaise, vomiting and vague abdominal discomfort. Over the past twelve hours he has become increasingly drowsy.

On examination, he was unresponsive to verbal commands. His temperature was 36.5°C and his blood pressure was 74/48 mmHg. The following investigations were done:

– Sodium: 121 mmol/L (137-144)
– Potassium: 6.2 mmol/L (3.5-4.9)
– Urea: 11.6 mmol/L (2.5-7.5)
– Creatinine: 162 µmol/L (60-110)
– Glucose: 1.1 mmol/L (3.0-6.0)
– Chloride: 91 mmol/L (95-107)
– Bicarbonate: 14 mmol/L (20-28)

After giving emergency treatment, what single investigation would be most valuable in confirming the diagnosis?