Archives: MRCP Part 2

MRCP2-3733

A 48-year-old woman with metastatic breast cancer is admitted to the Oncology Ward after experiencing vomiting and diarrhoea following her first cycle of paclitaxel chemotherapy. She is treated with intravenous fluids, electrolyte replacement, and antiemetics, and her symptoms quickly improve. However, on day three of admission, she continues to complain of abdominal pain despite the resolution of her treatment-related toxicities. A CT scan reveals multiple lung and liver metastases and mediastinal lymphadenopathy. She is currently taking paracetamol, ondansetron, sodium docusate, lansoprazole, and metoclopramide, but ibuprofen has been ineffective for her pain. Examination shows a tender liver edge palpable at roughly 3 cm from the costal margin. Her blood work shows a low hemoglobin level, normal white cell count, elevated ALT, and low serum albumin. What is the most appropriate management option?

MRCP2-3734

A 75-year-old man is admitted for pain management. He has a medical history of renal cell carcinoma with metastases to the pelvis and spine. Due to recent chemotherapy, he has developed renal impairment and his current creatinine level is 390. His performance status has declined in the past few months. The patient experiences pain only when he moves, and he prefers not to take regular pain medication due to past side effects. He is currently waiting for palliative radiotherapy and has requested an analgesic to use before movement. What is the most appropriate medication to prescribe for this patient?

MRCP2-3735

A patient with advanced metastatic adenocarcinoma of the lung is currently under your care. He is a former smoker and has a history of diabetes and peripheral vascular disease. Although he experiences little pain, he has a poor appetite and is frequently overcome by a frightening sensation of breathlessness. You have been summoned to visit him on the ward early in the morning.

Upon examination, there are no indications of chest infection, heart failure, or pleural effusion. His oxygen saturation levels are at 96% on air, but his respiratory rate is 26 and he appears to be in distress.

What would be the most appropriate immediate course of action?

MRCP2-3736

A 75-year-old man with a history of metastatic prostate cancer presents with worsening lower back pain that is aggravated by sitting upright. He reports difficulty sleeping at night but denies any sensory changes or weakness. His current medications include aspirin, paracetamol, and bicalutamide.

During the physical examination, the patient exhibits normal tone, full power, and downgoing plantars in both lower legs. However, he experiences extreme tenderness in the midline at L2 and L3.

Laboratory results show a bilirubin level of 34 µmol/l, ALP level of 450 u/l, ALT level of 56 u/l, albumin level of 32 g/l, and calcium level of 3.1mmol/l. An MRI of the spine reveals sclerotic lesions in T9, L2, and L3.

What is the most effective medical therapy for this patient?

MRCP2-3737

A 70-year-old man with progressive bulbar palsy MND (motor neurone disease) is scheduled for a percutaneous endoscopic gastrostomy (PEG) insertion to receive nutritional support. Due to the weakness of his bulbar muscles, he has been unable to eat properly for the past week, putting him at risk of developing refeeding syndrome once he starts receiving artificial nutrition. Which of the following blood test results would indicate the presence of refeeding syndrome?

Normal ranges:
Sodium 137-144 mmol/L
Potassium 3.5-4.9 mmol/L
Magnesium 0.75-1.05 mmol/L
Calcium 2.2-2.6 mmol/L
Serum phosphate 0.8-1.4 mmol/L

MRCP2-3738

A 55-year-old man has been admitted due to pain control and overall deterioration. He was diagnosed with metastatic lung cancer three years ago and has recently been found to have liver and bone metastases.

The patient has been experiencing significant pain control issues and has required increasing doses of opiates from his GP. At the time of admission, he was taking 200 mg morphine sulphate (modified release) twice daily.

The patient’s wife contacted his GP as he had become increasingly drowsy and nauseated over the past few days. She also expressed concern about significant lower limb jerks and mentioned that he had not passed urine in 24 hours.

What would be the most appropriate next step in managing this patient?

MRCP2-3739

What is a recognized indicator of opioid toxicity?

MRCP2-3740

A 25-year-old man has recently been diagnosed with non-Hodgkin’s lymphoma and has widespread mediastinal lymphadenopathy. He was scheduled to begin high dose chemotherapy for his potentially curable disease, but the day before his treatment was to start, he started experiencing a cough, dyspnoea, and headache.

The chemotherapy was postponed as he was suspected to have a chest infection and was prescribed broad spectrum antibiotics, but they had no effect. A repeat chest x-ray showed widening of the mediastinum, but it was unchanged from before. Over the next week, he developed facial oedema, tachypnoea, cyanosis, hallucinations, and prominent veins over his upper chest.

What investigation would you choose to confirm the acute diagnosis?

MRCP2-3741

A 68-year-old man with metastatic lung cancer is in the final stages of life and requires end of life care. The medical team plans to use a syringe driver to manage his symptoms as he cannot take medications orally. However, some medications may not be compatible when mixed together in a solution, leading to precipitation issues. Which of the following drug combinations can be safely mixed with water for injection in a syringe driver?

MRCP2-3742

You are requested to provide guidance on a patient who is in their late 60s and has metastatic renal cell carcinoma with pulmonary and bone metastases. They are receiving community palliative care at home, but their swallowing ability has started to decline. It is now believed that they are nearing the end stage of their illness, and a decision has been made to initiate a syringe driver. They have reported satisfactory pain management with their current analgesic regimen.

The patient’s current analgesic regimen consists of 60mg oxycodone modified-release capsules taken twice daily, along with oxycodone instant-release as needed. The oxycodone modified-release dose is converted to the equivalent subcutaneous dose for an oxycodone syringe driver.

What would be the appropriate dose of breakthrough analgesia to prescribe based on the current syringe driver dose?