Archives: MRCP Part 2

MRCP2-3787

A 25-year-old man with insulin-dependent diabetes mellitus (IDDM) visits the neurology clinic complaining of recurrent episodes of collapsing. These episodes involve a sensation of weakness that causes him to collapse to the ground. The episodes began about 8 months ago and happen multiple times a week. He does not believe that he loses consciousness during these episodes and has observed that emotional situations, particularly when he is laughing, can trigger the attacks. He has been feeling anxious and depressed lately, sleeping poorly with frequent nightmares.

His diabetes control has been poor in the past few months, and he has recently altered his insulin regimen to try to achieve better control. He has a sister who has a history of febrile convulsions.

What is the most probable diagnosis?

MRCP2-3786

A 49-year-old man presents to a psychiatric clinic following a referral from his GP due to his eccentric behavior. He has no medical history and is not taking any regular medications. There is no history of substance abuse.

Upon examination, he appears disheveled and is dressed entirely in black clothing. He is accompanied by his mother.

During the interview, it becomes apparent that he has always been perceived as strange by others and has difficulty forming social connections. He experiences anxiety in social situations and is fixated on ghosts, even going so far as to attempt to purchase ghost-hunting equipment. He occasionally feels the presence of spirits in his home as a cold breeze.

Throughout the interview, his affect is inappropriate, and he avoids eye contact while laughing at unusual points in the conversation.

What is the appropriate diagnosis for this personality disorder?

MRCP2-3794

A 17-year-old male is brought to the psychiatrist by his father, who is worried about his son’s inability to maintain healthy relationships. The patient himself denies any issues and claims to have many close friends.

During the consultation, the psychiatrist observes that he displays inappropriate sexual behavior and uses his physical appearance to seek attention. He also tends to exaggerate events and stories, always portraying himself as the main character. Many of his stories involve excessive emotional reactions.

What is the most precise diagnosis for this personality disorder?

MRCP2-3791

You are consulted for advice on a 55-year-old man who visited his primary care physician 12 weeks after experiencing an inferior myocardial infarction. He has been experiencing persistent low mood that fluctuates throughout the day, tearfulness, and hopelessness. He has lost 6 kg of weight in the past 3 months, and his BMI is currently 19. Although he has fleeting thoughts of suicide, he assures you that he would not act on them as he does not want to cause any harm to his family. The GP informs you that he was diagnosed with depression 20 years ago after an overdose of paracetamol and was prescribed Citalopram.

Aside from the recent MI, the patient also has a diagnosis of Atrial Fibrillation, for which he is taking warfarin. He has been experiencing epigastric pain for the past 2 years, and an OGD 1 year ago revealed that he required treatment for a duodenal ulcer with adrenaline. Although his symptoms of epigastric pain have decreased since then, they are still present. There has been no repeat OGD.

What would be the safest course of action?

MRCP2-3797

A 44-year-old woman visits the outpatient clinic for a check-up on her multiple sclerosis. During the conversation, she expresses her concerns about taking fluoxetine for her depression. She has read newspaper reports linking the drug to suicidal thoughts and wants to stop taking it. However, she has a long history of depression, and her symptoms have improved significantly since starting on fluoxetine 20 mg daily. She feels that her GP does not take her concerns seriously and does not have regular follow-up with psychiatrists. What would be the best course of action for her treatment?

MRCP2-3799

A 35-year-old woman is brought to the Emergency Department by her husband. He is very concerned because she appears to fall asleep suddenly during normal activities such as cooking, sometimes while walking and even whilst in the middle of a conversation. On examination her BMI is 28, with BP 140/70 mmHg. Neurological examination is unremarkable.

Investigations:
Haemoglobin 145 g/l 135–175 g/l
White cell count (WCC) 6.0 × 109/l 4–11 × 109/l
Platelets 200 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine 90 μmol/l 50–120 µmol
Fasting glucose 5.2 mmol/l < 7 mmol/l What is the most likely diagnosis for this patient?

MRCP2-3795

A 28-year-old woman with a known history of Obsessive-compulsive disorder (OCD) is seen in the Outpatient Clinic. She has come to the hospital with symptoms of a panic attack and is currently receiving treatment. She shares with you that she and her partner are considering starting a family, but she is worried that her child will also develop OCD. She asks if OCD is a hereditary condition.

What is the most evidence-based response to her question?

MRCP2-3796

A 45-year-old man presents to the Emergency Department with a complaint of severe chest pain that has been ongoing for the past 24 hours. He has been feeling generally unwell for the last six months since losing his job as a taxi driver. He lives alone at home following a recent divorce and has no significant medical history or family history. On examination, he is found to be trembling and sweaty with a heart rate of 130 bpm and regular blood pressure. His temperature is 36.9 oC. Investigations reveal normal results for haemoglobin, white cell count, creatinine, urea, bicarbonate, corrected calcium, phosphate, sodium, potassium, and troponin T. An echocardiogram shows sinus tachycardia with a normal ST segment, and a chest X-ray is unremarkable. Based on these findings, what is the most likely diagnosis?

MRCP2-3792

A 32-year-old woman presents to the Neurology Clinic. She has been struggling to keep up with her work and is experiencing difficulty sleeping at night. During the day, she often falls asleep unexpectedly, which is causing her significant embarrassment. These episodes tend to occur in stressful situations or when she is engaged in a lively conversation. To help her sleep, she has been drinking large amounts of alcohol in the evenings. Upon further questioning, she reports experiencing hypnagogic hallucinations. A friend suggested she try amphetamines to help her stay awake during the day. Neurological examination is unremarkable. Laboratory investigations reveal the following results:

Haemoglobin (Hb): 132 g/l (normal range: 135-175 g/l)
White cell count (WCC): 6.2 × 109/l (normal range: 4.0-11.0 × 109/l)
Platelets (PLT): 187 × 109/l (normal range: 150-400 × 109/l)
Sodium (Na+): 142 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+): 4.5 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Cr): 95 μmol/l (normal range: 50-120 µmol/l)
Urine toxicology screen: Amphetamines+

What is the most likely diagnosis for this patient?

MRCP2-3793

A 35 year old man comes to your haematology clinic with a 4 year history of fatigue, weight loss, and a feeling of fullness in the stomach. He has been absent from work for the past 3 months and has recently gone through a divorce. He also reports feeling low and has attempted suicide before. There is a family history of NHL. He has undergone investigations in the past, including CT scans, blood films, and lymph node biopsies, with the most recent set of investigations occurring 6 months ago.

Despite your reassurances that he does not have lymphoma, he remains convinced that he does and that he is dying. When you suggest a referral to a psychiatrist, he becomes very angry. What is the most probable underlying diagnosis?