Archives: MRCP Part 2

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?

MRCP2-3794

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?

MRCP2-3796

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?

MRCP2-3799

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?

MRCP2-3800

You are asked to evaluate a 68-year-old woman’s condition by psychiatry. Her husband has become increasingly worried about her behavior over the past three weeks. She has accused him of stealing my true husband and has become suspicious of him. Initially, she avoided her husband and refused to eat food he had prepared. However, today she threatened him with a knife, and the police had to be called.

The psychiatry doctor is concerned because she was admitted to the hospital five weeks ago and treated for a suspected urinary tract infection with intravenous antibiotics. Subsequent testing showed the pathogen to be an extended-spectrum beta-lactamase producing bacteria. She currently has a temperature of 38.7 degrees, heart rate 105 bpm regular, RR 18, and Sats 99% on room air. Her husband notes that she has been spending more time in the toilet over the past three weeks but is unsure if this is due to her paranoia.

Her husband describes an episode 30 years ago where she required antidepressants, antipsychotics, and ECT after a close family bereavement. She is otherwise healthy and has no history of cognitive problems. Her husband states that there is a strong history of mental health problems in her family, but he is unable to be more specific.

When you speak to her, she appears to be confused and scores 19/30 on the Mini Mental State Examination. She can point to, name, and recognize her husband and can also pick him out from pictures. However, she tells you that the man standing next to her is not her husband but a lookalike who has replaced him. Despite all your best efforts to show evidence to the contrary, she cannot be persuaded to change her opinion.

What is the best way to describe her presentation?

MRCP2-3771

An 17-year-old high-school student is brought to the Neurology Outpatient Clinic as an emergency extra due to three falls at home and crashing the family car. Her mother is concerned because she has started to walk funny. The patient has no medical history, is not on any medication, and denies smoking or using alcohol or illicit drugs. Her father has epilepsy, and her mother has type II diabetes mellitus and hypertension. One of her younger brothers had suffered from acute lymphoblastic leukaemia but is now in remission. She has recently broken up with her boyfriend of three years and has a pet dog and a parrot. She is three weeks away from taking her A-level examinations. On examination, she has a coarse tremor on movement, a broad ataxic gait, nystagmus, past-pointing, and diplopia. The rest of the exam was normal. Investigations reveal abnormal results for Haemoglobin, White Cell Count, Sodium, Creatinine, Bilirubin, and Alanine aminotransferase. CT head demonstrates a normal brain, and no abnormalities are seen on U/S liver and bile ducts are of normal calibre. What is the most likely diagnosis?

MRCP2-3772

A 25-year-old woman presents to the Emergency Department after collapsing at home. According to the paramedic sheet, she is suspected to have had a significant overdose and appropriate treatment has been initiated. Her sister reports that she has not been the same over the past year, following a traumatic event where she was raped. She has developed an obsession with her weight and refuses to eat, often vomiting. On examination, she has a BMI of 16 kg/m2, fine lanugo covering her face, and cuts on her arm. Her vital signs are stable, but her blood work shows a low haemoglobin level, low potassium, and low corrected calcium. What is the most likely diagnosis?

MRCP2-3773

A 32-year-old man presents to the Emergency Department (ED). He has overdosed on antidepressants, which was staggered over the last 72 hours. He was brought into the hospital after being found at home, unconscious, surrounded by several empty packets of antidepressants and empty bottles of alcohol. Over the last year, he has presented to the ED three times with attempted suicide.

He has now been in the ED for 8 hours and has been initiated on appropriate treatment. His blood tests show no abnormalities. He is accompanied by his sister, who tells you that a psychiatrist has never seen her brother because of early self-discharge.

The patient’s sister informs you that her brother goes through several phases. Some days he feels well and goes to the gym, socializes with friends, and sometimes stays awake for two or three days at a time. Good days tend to run in periods of 2-3 weeks. A few weeks after these episodes, he becomes withdrawn, isolates himself, and refuses to eat or communicate and these low periods in turn may last for weeks. This all started in his early twenties.

Which of the following best describes this patient’s mood disorder?

MRCP2-3770

A 42-year-old man has been referred to the General Nephrology Clinic by his General Practitioner (GP) due to persistent thirst and frequent nocturia. He has a history of depression and has been on antidepressant medication for several years. During his last depressive episode, he was initiated on lithium treatment and has been on it since then.

He reports drinking up to five litres of water in a day but is still persistently thirsty. He passes large amounts of urine throughout the day and wakes up to urinate at least four times per night. He denies any headache, fever, urinary discomfort, or malaise. Additionally, he does not have dry eyes.

On examination, he appears tired and has a mild tremor in both his hands. Investigations reveal normal haemoglobin, sodium, phosphate, bicarbonate, corrected calcium, creatinine, and urea levels. The mid-stream urine (MCS) and urine dip are negative. An ultrasound shows a radiologically normal renal tract with no evidence of hydronephrosis, normal cortico-medullary differentiation, and normal vascularity.

What is the most likely diagnosis?

MRCP2-3776

A 25-year-old male is admitted after a paracetamol overdose. He took fifteen 500mg tablets. He states that he wants to end his life and that he sees no purpose in living anymore. He had left a note for his girlfriend. On mental state examination, he displays poverty of thought, a flat affect, and signs of nihilistic delusions. He has a history of severe depression. Although he is medically stable, he is transferred to a psychiatric unit for further evaluation due to persistent suicidal thoughts. During his stay, he develops catatonia and refuses to eat or drink.

Is there an absolute contraindication for electroconvulsive therapy in this case?