MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1520

A 30-year-old man presents to the clinic with his partner due to difficulties with fertility, having tried to conceive for over 24 months with no success. He reports decreased libido and trouble maintaining his erection. He has also experienced problems with his sense of smell for as long as he can remember. On physical examination, his blood pressure is 120/70 mmHg, with a pulse of 75/min. He has sparse secondary sexual hair and a small penis.

Investigations reveal a hemoglobin level of 124 g/l, a white blood cell count of 7.1 x 109/l, and a platelet count of 203 x 109/l. His sodium and potassium levels are within normal limits, but his creatinine level is 110 µmol/l. His TSH level is 1.2 U/l (0.5-4.5 U/l), and his free T4 level is 12 pmol/l (10-22). His testosterone level is 7.0 nmol/l (9–35), while his FSH and LH levels are both low.

What is the most likely diagnosis?

MRCP2-1501

A 25-year-old man with a history of Von Hippel Lindau syndrome presents to his GP for a routine mood review. He has previously been well but has retinal haemangiomas. He is currently taking venlafaxine for improved mood following a recent relationship break down. Despite using mindfulness to control panic attacks, he still experiences palpitations and clamminess.

During the examination, the patient appears alert and in good health. However, his blood pressure is measured at 170/110 mmHg. Fundoscopy reveals no haemorrhages or cotton wool spots, and his visual acuity is 6/6 bilaterally. There are no palpable masses in his abdomen.

The patient’s blood test results show normal levels of Na+, K+, HCO3, urea, and creatinine, but his TSH level is 3.2 mU/l (range 0-4). An ECG reveals large QRS complexes consistent with left ventricular hypertrophy.

What is the most likely explanation for the patient’s symptoms?

MRCP2-1502

A 25-year-old woman presents to the Emergency department following a collapse at the local supermarket. She reports feeling weak and fatigued most of the time and rarely seeks medical attention. She has no regular medication. On examination, her blood pressure is 100/70 mmHg, pulse is 80 beats per minute and regular. She has a BMI of 21 kg/m² and no abnormal physical signs are noted.

Investigations

Na+ 140 mmol/l
K+ 3.1 mmol/l
HCO3- 32 mmol/l
Urea 5.9 mmol/l
Creatinine 85 µmol/l

What is the most likely diagnosis?

MRCP2-1503

A 24-year-old woman with a history of polycystic kidney disease and chronic kidney disease presents to the Endocrinology Clinic for her annual review. She reports experiencing intermittent abdominal pain and generalised aches over the past two weeks, as well as feeling thirsty. She is currently on the waiting list for a kidney transplant. Her routine blood tests reveal several abnormalities, including a low haemoglobin level, high white cell count and platelet count, elevated urea and creatinine levels, and a high calcium level. What condition has this patient developed that could explain the abnormal calcium level?

MRCP2-1504

A 63-year-old male, who recently immigrated from India, presents with a 5-day history of feeling generally unwell. His niece, who is with him at the hospital, denies any recent productive cough, diarrhea, vomiting, or dysuria. The patient has been gradually becoming more malaised over the past 5 days and has not been eating or drinking well. He has no known medical history. On examination, he has dry mucous membranes and cool peripheries, and his JVP is +1 cm above the angle of Louis. Heart sounds, chest, and abdomen are unremarkable. Urine dip and chest radiograph results are pending. The patient’s blood tests reveal:

– WBC: 16 * 109/l
– Neutrophils: 14.8 * 109/l
– Na+: 152 mmol/l
– K+: 3.7 mmol/l
– Urea: 22 mmol/l
– Creatinine: 208 µmol/l
– CRP: 38 mg/l
– Glucose: 38 mmol/l
– Ketones: 2.8 mmol/l

Arterial blood gases:

– pH: 7.31
– PaO2: 20.2 kPa
– PaCO2: 3.0 kPa
– Bicarbonate: 16 mmol/l
– Lactate: 4 mmol/l

What is the likely diagnosis that unifies these symptoms and test results?

MRCP2-1490

A 25-year-old woman with a history of anorexia presents to her primary care physician with vomiting and stomach discomfort.
Investigations:

Urea 18 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 90 µmol/l 50–120 µmol/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Corrected calcium (Ca2+) 3.5 mmol/l 2.2–2.6 mmol/l
Plasma parathyroid hormone (PTH) 8.5 pmol/l 0.9–5.4 mmol/l
Initiation of fluid resuscitation with 0.9% sodium chloride is commenced.
What would be the subsequent step in management after fluid resuscitation?

MRCP2-1491

A 45-year-old male presents with a six-month history of impotence and reduced libido. He has been married for 20 years and has two children. He smokes five cigarettes per day and drinks approximately 12 units of alcohol weekly.

On examination, he appears obese but otherwise phenotypically normal with normal secondary sexual characteristics. His blood tests show normal electrolytes, liver function, and fasting glucose levels. His T4 and TSH levels are within normal range, as is his prolactin level.

However, his testosterone level is low at 6.6 nmol/L (normal range is 9-30), while his LH and FSH levels are elevated at 23.7 mU/L (normal range is 4-8) and 18.1 mU/L (normal range is 4-10), respectively.

Which additional investigation would you choose to further evaluate this patient’s condition?

MRCP2-1492

A 57-year-old unemployed man presents to hospital with complaints of weight loss and weakness. He has difficulty climbing stairs and rising from his armchair at home. He lives alone and drinks 50 units of alcohol per week while smoking 20 cigarettes daily for 40 years. His blood pressure is 197/98 mmHg. Upon investigation, his Hb is 99 g/L, WBC is 9.8 ×109/L, platelets are 350 ×109/L, sodium is 145 mmol/L, potassium is 2.8 mmol/L, urea is 4.1 mmol/L, creatinine is 120 µmol/L, bicarbonate is 35 mmol/L, and glucose is 12.9 mmol/L. An arterial blood gas shows a pH of 7.26. Which investigation would be most useful in determining the cause of his illness?

MRCP2-1493

A 35-year-old female presents to the emergency department as a stand-by due to feeling unwell for the past 2 weeks. She reports experiencing lethargy, occasional shortness of breath, and light-headedness. Recently, she has also been experiencing urinary frequency and dysuria. Her general practitioner visited her at home 2 days ago and prescribed trimethoprim for a possible urinary tract infection.

Upon arrival, the patient appears pale and clammy, with cold peripheries. Her vital signs reveal oxygen saturations of 94% on air, a respiratory rate of 28/min, a heart rate of 117/min, and a blood pressure of 65/30 mmHg.

The patient has a medical history of type 1 diabetes, hypothyroidism, and uterine fibroids.

Initial investigations show:

– White cell count: 17.8 *109/l
– Haemoglobin: 97 g/l
– Mean cell volume (MCV): 103.7 fL
– Sodium: 134 mmol/l
– Potassium: 4.9 mmol/l
– Urea: 7.0 mmol/l
– Creatinine: 120 µmol/l
– Bilirubin: 45 µmol/l
– Alanine transaminase (ALT): 1051 U/l
– Albumin: 16 g/l
– C-reactive protein (CRP): 71 mg/dL
– Glucose: 9.1 mmol/l

Urinalysis shows: ++protein, ++blood, +++leukocytes, ++nitrites, trace ketones.

The patient is given intravenous fluids, and her blood pressure increases to 82/45 mmHg after receiving a total of 3 litres of fluids. She is started on intravenous amoxicillin and gentamicin.

What is the next step in managing this patient?

MRCP2-1494

A 65-year-old woman with a history of type 2 diabetes presents for a check-up. She has a mild cardiac failure that is being managed with ramipril and bisoprolol. Her current medication for diabetes is metformin 1g BD. During examination, her blood pressure is 122/82 mmHg, pulse is regular at 80 beats per minute. Bilateral basal crackles are heard on auscultation of the chest, and there is pitting oedema of both ankles. Her body mass index is elevated at 33 kg/m².

HbA1c 73 mmol/mol
Creatinine 82 µmol/l

What is the most appropriate next step for managing glucose control?