Archives: MRCP Part 2

MRCP2-3784

You are requested to evaluate a 35-year-old woman who is experiencing emotional turmoil. She reports having episodes of intense anxiety and fear for the past eight months, accompanied by palpitations, tremors, sweating, and a sensation of suffocation. She cannot identify any specific trigger for her symptoms. These episodes, which typically last 10-15 minutes, occur in various situations, including when she is at ease. However, they are most frequent when she is riding on an escalator. She has no psychotic symptoms and has visited the emergency department twice, believing she was having a heart attack, but all tests were normal. She had similar episodes five years ago, which gradually resolved. Her mother had depression, and her father died of a heart attack at the age of 45. She is in good overall physical health, alert and oriented, with only minor concentration difficulties and intact cognitive abilities. Which brain region is most likely involved in this patient’s condition?

MRCP2-3785

A 35-year-old female presents to the Emergency department with sharp, stabbing abdominal pain that has been present for several days. She reports feeling nauseated but has not vomited and has not noticed any changes in bowel or urinary habits. Her periods are irregular but not heavy, and her last period was two weeks ago. She had previously attended another hospital where she underwent various investigations, including an ultrasound of the abdomen, which all came back normal. However, she believed that the staff were incompetent and that something was amiss, resulting in her being escorted out of the hospital by security due to aggressive outbursts. On examination, she appeared cooperative and animated, with multiple recent scars across her abdomen and left arm. She occasionally takes cocaine and drinks 20 units of alcohol per week, and she lives with her boyfriend and is unemployed. Her vital signs are normal, and her tests show a haemoglobin level of 155 g/L, mean cell volume of 95 fL, white cell count of 6.1 ×109/L, platelets of 202 ×109/L, serum sodium of 139 mmol/L, serum potassium of 4.2 mmol/L, serum urea of 4.9 mmol/L, and serum creatinine of 78 µmol/L. What does this patient exhibit?

MRCP2-3759

A 55-year-old male presents to the emergency department with a 4-week history of constipation not relieved by over the counter laxatives. His past medical history was significant for hypertension, COPD and schizophrenia. His current medications include ramipril, clozapine and tiotropium. He denied weight loss, poor appetite or other alarming symptoms. His family history was significant for bowel cancer with his father and uncle having died of colon cancer aged 78 and 82 respectively. His sister had a hysterectomy at the age of 72 but he was not sure why.

On examination, his blood pressure was 126/80 mmHg lying and 118/82 mmHg standing. Pulse was 65/min. Clinical examination did not reveal any significant findings.

Investigations:

Hb 135 g/l
MCV 83 fl
Platelets 410 * 109/l
WBC 6.8 * 109/l
Creatinine 91 umol/L
Urea 4.5 umol/L
Na+ 142 mmol/L
K+ 4.0 mmol/L
Corrected Calcium 2.4mmol/L
FOB negative
Abdominal X-ray faecal loading

What is the most likely cause of constipation in this case?

MRCP2-3760

A 32-year-old male presents for follow-up. He has a history of schizophrenia that is currently being managed with quetiapine, as he did not respond well to olanzapine and risperidone in the past. He reports persistent derogatory auditory hallucinations in the third person. You decide to initiate clozapine therapy.

Before starting clozapine, what other essential investigation should be conducted?

Baseline blood tests reveal:

– Hemoglobin (Hb): 145 g/l
– Platelets: 320 * 109/l
– White blood cells (WBC): 6.8 * 109/l
– Neutrophils: 3.8 * 109/l

MRCP2-3761

A 45-year-old man presents with significant mood swings that began a month after he had an asymptomatic thyroid nodule removed two years ago. He experiences about three weeks of intense energy, euphoria, and hyperactivity followed by a week of depression where he sleeps excessively and feels immobile. This pattern of alternating periods of depression and elation, with a few ‘normal’ days, has occurred multiple times since. The patient denies any substance abuse. Mild thyroid hypofunctioning was detected in his last thyroid function tests, but there are no clinical signs of thyroid disease on examination. What is the most probable diagnosis?

MRCP2-3762

A 32-year-old woman is found wandering the streets on Christmas Day and is brought by the police to the Emergency Department. She is wearing minimal clothing and appears to have marks across her back from a whip. On further questioning she tells you that she is Mary, and knows this because god spoke to her through the radio. She is happy to accept treatment from you because she believes you are one of her disciples. The nurses check her records against a driver’s license found in her pocket, and see that she has attended on 2 previous occasions because of drug intoxication. On examination her BP is 130/80 mmHg; pulse is 90/min and regular. She is sweating and looks anxious. General physical is unremarkable although she appears unkempt and her BMI is 20.2.

What is the most appropriate course of action in this situation?

MRCP2-3763

Olivia, 27, has treatment resistant schizophrenia, with her usual symptoms being auditory hallucinations and persecutory delusions. She was recently prescribed clozapine, fluoxetine and lactulose. She has been complaining of constipation recently, but now presents to the emergency department with acute abdominal pain and vomiting. On examination abdomen is distended. What is the most probable reason for her symptoms?

MRCP2-3764

A 55-year-old man presents to the Emergency Department with fevers and feeling generally unwell for the past 3 days. He recently returned from a 2 week stay with his brother who lives in a different state. He reports a mild non-productive cough and shortness of breath, but denies any vomiting, diarrhea, dysuria, or abdominal pain. His medical history includes epilepsy, schizophrenia, hypertension, and diet-controlled type 2 diabetes. On examination, he has a temperature of 38.3 ºC, heart rate of 111 beats per minute, and blood pressure of 118/75 mmHg. His chest x-ray is clear and blood tests reveal a low white blood cell count and elevated CRP. Which medication is most likely responsible for his current condition?

MRCP2-3766

A 40 year old caucasian man visits his doctor due to concerns about sudden weight gain. He has gained 8kg in the past 6 months despite maintaining his usual diet and exercise routine. The doctor decides to conduct further tests and discovers the following irregularities. The patient informs the doctor that he was previously taking medication for bipolar disorder, but it was changed a year ago due to abnormal movements. He has also been taking medication for nausea and recently started taking medication for breast enlargement.

Hemoglobin: 13.5 g/dl
Platelets: 150 * 109/l
White blood cells: 4.0 * 109/l
Neutrophils: 1.8 * 109/l
Lymphocytes: 1.2 * 109/l
Eosinophils: 1.0 * 109/l

Fasting blood sugar: 11.2 mmol/l
Prolactin: 270 mu/l

Electrocardiogram: sinus rhythm 80/min QTC 470 ms

Which medication is most likely responsible for these abnormalities?

MRCP2-3767

A 35-year-old man presents to the Emergency Department with complaints of sudden weakness in his left arm and leg for the past 30 minutes. He reports no significant medical history or family history of stroke or heart disease.
On examination, his blood pressure is 130/80 mmHg, heart rate 72 bpm, and respiratory rate 18 breaths/min. The power of the left arm and leg is 0/5, while the right arm and leg have full strength. The bilateral plantar response is flexor.
What is the most appropriate course of action for managing this patient?