A 25-year-old man presents to the Neurology Clinic with complaints of disrupted sleep patterns and sudden episodes of muscle weakness. He reports falling asleep during important tasks and experiencing up to ten episodes of collapse during emotional situations. He has no significant medical history and his vital signs are within normal limits. Physical examination reveals no neurological abnormalities and routine blood tests are normal. What is the most effective intervention for managing his cataplexy symptoms?
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.
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?
MRCP2-3768
A 42-year-old woman is brought to the Emergency Department by her husband. She tells you that she is not real and is living in a dream, that she does not exist in this world. Her husband tells you that she barely eats, sleeps for long periods in the day and wakes in the early hours of the morning. She says she became preoccupied and very low in mood after some problems at work. Most recently, she had tried to jump out of the car whilst they were driving to the hospital. On examination, she stares continuously at the wall, mumbling only that she is in a dream, nothing is real and she’s not really here. She looks unkempt and as if she has not been taking good care of herself. Investigations: Haemoglobin (Hb) 142 g/l 135 – 175 g/l White cell count (WCC) 5.2 × 109/l 4.0 – 11.0 × 109/l Platelets (PLT) 189 × 109/l 150 – 400 × 109/l Sodium (Na+) 137 mmol/l 135 – 145 mmol/l Potassium (K+) 4.2 mmol/l 3.5 – 5.0 mmol/ Creatinine (Cr) 90 µmol/l 50 – 120 µmol/l Thyroid-stimulating hormone (TSH) 2.8 mu/l 0.4 – 5.0 mu/l Which of the following treatments is most likely to be effective in this case?
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?
MRCP2-3745
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?
MRCP2-3746
A 55-year-old woman with renal cell carcinoma and bone metastases throughout her body presented at the outpatient clinic. She had previously experienced back pain and had undergone two rounds of palliative radiotherapy in the last six months to her upper lumbar and lower thoracic spine, which had been effective. However, during her visit, she reported that her back pain had returned and was currently limiting her mobility. Upon examination, tenderness was noted over the T11 and L1 vertebrae. Her current pain management regimen included MST 90 mg BD, diclofenac SR 75 mg BD, and oramorph 30 mg prn. What is the most appropriate treatment for her back pain?
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?
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?
MRCP2-3749
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?