MRCP Part 2 Category: Endocrinology, Diabetes And Metabolic Medicine

MRCP2-1478

A 49-year-old woman presents with a 2-month history of fatigue, anorexia and nausea. She has also noticed some darkening of the skin on her hands. Prior to this, she was fit and well, with no significant past medical history. She has a strong family history of Graves’ disease.

On examination, there is some evidence of wasting of the face, and noticeable hyperpigmentation of the palmar creases. Her blood pressure is 105/75 mmHg. Blood tests are taken:

Na+ 134 mmol/L (135 – 145)
K+ 5.3 mmol/L (3.5 – 5.0)
Urea 6.8 mmol/L (2.0 – 7.0)
Creatinine 76 µmol/L (55 – 120)
Calcium 2.43 mmol/L (2.1-2.6)
Thyroid stimulating hormone (TSH) 1.2 mU/L (0.5-5.5)
Free thyroxine (T4) 13.3 pmol/L (9.0 – 18)

What subsequent test can be conducted to differentiate between a primary and secondary cause of the likely diagnosis?

MRCP2-1479

A 35-year-old alcoholic presents with abdominal pain and vomiting. His amylase is 1200 U/l and he is being treated for acute pancreatitis. You are called to see him as the nursing staff report the patient is becoming restless. He complains of numbness around his mouth and appears to be in some discomfort.

Your foundation year 2 colleague notes this morning’s blood results:

Adjusted calcium 1.8 mmol/l
Na+ 136 mmol/l
K+ 3.7 mmol/l
Urea 6.9 mmol/l
Creatinine 81 µmol/l

What is the next step in management?

MRCP2-1480

A 35-year-old woman presents to the hypertension clinic with difficult-to-control hypertension. She reports occasional aches and pains that mainly affect her arms and legs, as well as an increase in urinary frequency and urgency. Her blood pressure reading at the clinic is 175/95 mmHg. She is currently being treated with amlodipine and lisinopril for hypertension. Blood tests taken prior to her visit show normal electrolyte levels and mildly elevated creatinine. An aldosterone and renin test reveals an increased aldosterone-to-renin ratio, and a CT abdomen confirms bilateral adrenal hyperplasia. What is the most appropriate management for this patient?

MRCP2-1481

A 25-year-old woman with a history of partial Kallmann syndrome presents to the fertility clinic seeking advice on starting a family. She has been married for 6 months and has normal external genitalia, sparse pubic and axillary hair, and a body mass index of 23kg/m². What is the most suitable course of action for her?

MRCP2-1482

A 60-year-old man with a 35-year history of type 1 diabetes mellitus presents to the clinic for follow-up. He has peripheral diabetic sensory neuropathy, impotence, and has undergone laser therapy for bilateral diabetic retinopathy. His primary concern is experiencing unpredictable vomiting of undigested food, despite dietary modifications. During a previous hospitalization, erythromycin was effective in treating the condition. A barium swallow revealed significantly prolonged gastric emptying.

What is the most suitable long-term management plan for this patient?

MRCP2-1483

A 17-year-old male patient comes to the clinic with complaints of inadequate development of secondary sexual characteristics. Upon examination, you observe insufficient testicle growth and minimal axillary and pubic hair.

The blood test results are as follows:

Testosterone 2.5 nmol/L (6 -27)
FSH 4.2 IU/L (1.8 – 22.5)
LH 3.1 IU/L (1.2 – 103)

What is the probable diagnosis?

MRCP2-1484

A 42-year-old man presents to the Neurology clinic for assessment. He has a history of migraine with aura and is currently taking topiramate. No other medications are being taken. The following investigations were conducted:

– Na+ 138 mmol/L (135 – 145)
– K+ 3.1 mmol/L (3.5 – 5.0)
– Urea 5.7 mmol/L (2.0 – 7.0)
– Creatinine 78 µmol/L (55 – 120)

Venous blood gas:

– pH 7.29 (7.35 – 7.45)
– Bicarbonate 16 mmol/L (22 – 29)

Urinalysis:

– Glucose 3+
– Protein 2+
– Blood negative

What is the most likely diagnosis?

MRCP2-1485

A 45-year-old woman presents with a history of recurrent lethargy, shakiness, slurred speech, and diplopia for the past year. Her symptoms usually occur in the mornings and resolve after breakfast. She has a medical history of type 2 diabetes mellitus, alcohol excess, and a functional neurological disorder.

Upon observation, her SpO2 is 97% on room air, respiratory rate is 22 breaths/minute, blood pressure is 92/64, heart rate is 116 beats per minute, and she is apyrexial. Her capillary blood glucose is 5.2, but during the review, she becomes shaky and feels unwell. A repeat blood glucose test shows 2.4.

Blood tests are ordered, and 40% dextrose gel is administered. The results of the blood tests show insulin levels of 43 pmol/L (<25), C-peptide levels of 114 pmol/L (<75), and pro-insulin levels of 23 pmol/L (3.6-22). What is the most likely diagnosis?

MRCP2-1486

A 35-year-old male with a history of asthma and HIV visits the HIV clinic for a check-up. He has been experiencing weight gain, marks on his abdomen, and his partner has noticed a more heavy-set appearance in his face over the past two months. He was diagnosed with HIV at 21 years old after sharing needles and using heroin. He has been on retroviral treatment since he was 22, taking tenofovir, emtricitabine, atazanavir, and ritonavir, and has had good control. His asthma has been well managed with only salbutamol until six months ago when he started taking regular fluticasone due to recurrent exacerbation from upper respiratory tract infections. His recent blood tests show an undetectable viral load and a CD4 count of 900 cells/microliter. What is the most likely explanation for his symptoms?

MRCP2-1487

A 20-year-old woman presents to her GP with a 6 month history of weight loss, diarrhoea and palpitations. The diarrhoea is normal colour and over the last two months she has had roughly 2-3 bowel motions per day. The heart palpitations occur randomly throughout the day and night. She has also noticed that she has recently been getting episodes of feeling very hot and sweaty. She has no other past medical history and her only family history is a mother who has Hashimoto’s thyroiditis.

On examination, the patient is sweaty and her blood pressure is 130/80 mmHg, pulse is 102 bpm and regular, respiratory rate is 16/min and her oxygen SATs are 98% on air.

Blood tests are performed and reveal:

Hb 135 g/l
Platelets 220 * 109/l
WBC 7.1 * 109/l
Na+ 139 mmol/l
K+ 3.9 mmol/l
Urea 5.1 mmol/l
Creatinine 60 µmol/l
Free thyroxine (T4) 28 pmol/l
Thyroid stimulating hormone (TSH) 0.08 mu/l

A thyroid radioisotope scan is performed and reveals a globally reduced uptake.

What is the most likely diagnosis?