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?
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.
Which medication is most likely responsible for these abnormalities?
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?
MRCP2-3767
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?
MRCP2-3748
A medical consultation was requested for a 57-year-old man admitted with pneumonia who was experiencing persistent hiccups. He had been diagnosed with hepatocellular carcinoma six months prior and was not eligible for curative treatment due to the extent of the disease. Despite initially being asymptomatic, he had developed hiccups over the past four weeks. His GP had attempted to treat the hiccups with domperidone and haloperidol in collaboration with the palliative care nurse, but there was no improvement in his symptoms. He reported feeling fatigued but denied experiencing any other symptoms such as abdominal pain, heartburn, or early satiety.
The patient’s medical history included alcohol dependence syndrome, chronic liver disease, hypertension, and hypercholesterolemia. He was prescribed thiamine 100mg TDS, lactulose 10 mls BD, spironolactone 100mg OD, propranolol 40mg OD, simvastatin 20 mg OD, and intravenous co-amoxiclav 625mg TDS for the treatment of his pneumonia. Upon examination, he appeared cachectic, and a palpable mass was detected in the right upper quadrant inferior to the right sternal edge. Ascites was also present, but there was no tenderness. Neurological, cardiovascular, and respiratory examinations were unremarkable. Recent investigations revealed elevated levels of bilirubin, ALP, and ALT, as well as low levels of protein and albumin. A chest x-ray showed normal heart borders and lung fields, and a surveillance upper GI endoscopy four months ago revealed a normal stomach mucosal surface with no evidence of portal hypertension.
What is the best course of action for managing the patient’s hiccups?
MRCP2-3745
A 67-year-old man with metastatic squamous cell lung cancer is admitted to the Acute Medical Unit for the management of hypercalcaemia. He is currently taking slow-release morphine sulphate (MST) 90 mg bd to control his pain along with regular naproxen and paracetamol. While in the hospital, he reports experiencing pain in his right arm, which is the location of a known skeletal metastasis. What medication would be the best choice to alleviate his acute pain?
MRCP2-3749
You are requested to evaluate a 68-year-old man who was admitted to the emergency department with pneumonia. He had been diagnosed with advanced small cell lung cancer that had spread extensively to his liver, thoracic vertebrae, and femur bones. His medical history included ischemic heart disease, hypertension, hypercholesterolemia, and COPD.
The patient’s primary complaint was of increasing pain in his legs and spine, which was particularly bothersome at night. Despite a trial of bisphosphonate therapy and radiotherapy, he did not experience any relief. He was initially prescribed oral morphine sulfate solution, which was later switched to morphine sulfate tablets (MST). He had been taking 60mg BD, but the palliative care community nurse titrated it to 70 mg BD a few days before admission, resulting in excellent pain relief. He also used Oramorph solution 10mg approximately 5-6 times a day for breakthrough pain.
While on the ward, he received intravenous antibiotics and made a full recovery. Before discharge, he expressed a strong desire to start transdermal treatment to reduce the number of oral medications he was taking.
What is the most appropriate initial dose to begin transdermal treatment, with the goal of completely discontinuing all oral opiate medication?
MRCP2-3750
A 65-year-old man has been admitted to the urology department due to difficulty passing urine and back pain. A bladder scan revealed 980 mls of urine in his bladder, and he was catheterized by the admitting doctor, which resulted in haematuria. The patient has a medical history of metastatic prostate cancer, hypertension, hypercholesterolemia, hypothyroidism, atrial fibrillation, and a previous NSTEMI. He is currently taking warfarin and modified-release morphine 30 mg every 12 hours.
The urology consultant has recommended inserting a 3-way catheter if the haematuria persists and referring the patient to the palliative care team for pain management. The palliative care specialist has suggested increasing the modified-release morphine to 45 mg every 12 hours.
What is the appropriate dosage of immediate-release morphine for the patient’s breakthrough pain?
MRCP2-3744
A 29-year-old woman with metastatic cervical cancer presents to the Medical Admissions Unit with uncontrolled pain and vomiting. She has been experiencing worsening back and pelvic pain for the last two weeks, but was reluctant to seek medical attention as she wanted to keep going for her three young children. Despite palliative treatment, her pain has become unbearable and she is now clinically dehydrated and in distress. Her lab results show elevated levels of serum urea, creatinine, and corrected calcium, as well as low albumin. What is the most appropriate analgesic for this patient?
MRCP2-3747
In 1996, the World Health Organisation created a three-stage ‘ladder’ for managing cancer pain. Can you identify the drug that is located on the second step of this ladder?