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?
MRCP2-3797
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?
MRCP2-3798
A 26-year-old female is experiencing difficulty walking while recovering from spinal surgery in an inpatient rehabilitation unit. The surgery was performed six weeks ago by neurosurgeons from T2 to T4 to evacuate a spinal hematoma after she fell while playing netball. The patient has no prior medical history and gave birth to a healthy baby boy 18 months ago.
During examination, the patient exhibited normal tone in her upper and lower limbs. Her power was 5/5 on the MRC power scale, and she had normal sensation to cotton wool, pin prick, and proprioception. Reflexes were present (2+) in her biceps, triceps, supinator, patella, and ankles, and both plantars were downgoing. However, her gait was markedly abnormal, with both feet sliding along the floor for 80 meters without lifting between steps. The patient’s cognition was intact. What is the best course of action?
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?
MRCP2-3770
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?
MRCP2-3771
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?
MRCP2-3775
A 40-year-old female presents with symptoms of polyuria, nocturia, and general lethargy that have been ongoing for two months. She has a history of psychiatric illness and is currently taking medication for it. The patient is a smoker, consuming 12 cigarettes per day, and drinks approximately five units of alcohol per week.
During examination, the patient is found to be obese with a BMI of 32.3 kg/m2, a pulse of 82 beats per minute, and a blood pressure of 142/88 mmHg. No abnormalities are noted during the examination.