Archives: MRCP Part 2

MRCP2-3743

An 87-year-old man was admitted to the acute medical admissions unit due to acute confusion referred by his GP. The patient was prescribed trimethoprim 200mg BD for a presumed urinary tract infection three days ago, after his nursing home reported new urinary incontinence and offensive smelling urine. Unfortunately, his condition worsened, and he became confused and unable to mobilize, leading to the admission. The patient’s medical history included Alzheimer’s disease, hypertension, hypercholesterolemia, and osteoarthritis. He was taking donepezil 10 mg OD, amlodipine 5mg OD, atorvastatin 20mg ON, and paracetamol 1g QDS. The patient was usually able to mobilize independently and had intermittent confusion, but he could hold lucid conversations with his care workers. He had no lasting power of attorney or advanced directive in place, and his daughter, who resided abroad, had not contacted him in several years.

During the examination, the patient’s temperature was 39.6ºC, heart rate 122 bpm, respiratory rate 26/min, and blood pressure 97/58 mmHg. The cardiovascular system examination revealed a bounding peripheral pulse and a capillary refill time of three seconds. The respiratory system examination revealed tachypnea, and the abdominal examination revealed no abnormalities. The patient was not compliant with formal neurological examination, and his GCS was 14 (E4 S4 M6). He was very confused and unable to maintain a formal conversation, and his speech did not resemble any form.

When the doctor attempted to perform venous cannulation, the patient became very aggressive and hostile. He refused all forms of treatment, stating that he did not require medical treatment and requested to leave the ward immediately. The patient did not appear to comprehend the risks of refusing medical admission and was unable to recall the information disseminated.

What is the best course of action for managing this patient?

MRCP2-3717

A 67-year-old man is admitted to the hospital for palliative radiotherapy. He has a squamous cell carcinoma of the throat that has spread to his neck and is surrounding the carotid artery. Unfortunately, there are no surgical options available to treat his condition.

On the second day of his admission, he suffers from a severe bleed from his neck.

What medication would be the most suitable to administer in this situation?

MRCP2-3718

A 49-year-old woman has been diagnosed with extensive small cell carcinoma of the lung. She is experiencing proximal muscle weakness in her arms and legs, a waddling gait, diplopia, a dry mouth, and diminished reflexes. Which of the following treatments would be inappropriate?

MRCP2-3719

A 79-year-old man is being seen by the palliative care team while on the ward. He has a history of metastatic lung cancer and is no longer a candidate for chemotherapy, surgery, or radiotherapy. His condition has rapidly declined in the past few days and he is believed to be in the final days of his life. He is experiencing severe nausea that is difficult to manage.

Which medication would be the most suitable for alleviating his symptoms?

MRCP2-3720

A 67-year-old woman with colon cancer and liver metastases is experiencing pain. Her most severe pain is a constant ache in the right upper quadrant that does not seem to be relieved by immediate release morphine (such as Oramorph). She is currently on modified release morphine 30 mg twice a day, paracetamol 1 g four times a day, and Oramorph 10 mg as needed. What is the best course of action for managing her pain?

MRCP2-3723

A frail 87-year-old man with metastatic prostate cancer is admitted from a nursing home with abdominal discomfort and constipation. He typically experiences fecal incontinence every day but has not had a bowel movement in over a week. An abdominal x-ray reveals severe constipation but no signs of bowel obstruction.

Currently, he is taking paracetamol 1 g qds, diclofenac 50 mg tds, and MST (modified release morphine sulphate) 20 mg bd for back pain caused by bony metastases. What is the most appropriate treatment for this patient’s constipation?

MRCP2-3724

A 68-year-old man presents to the Emergency Department complaining of chest pain and difficulty breathing. He has a medical history of metastatic adenocarcinoma of the colon, which was diagnosed 10 months ago and treated with a palliative colectomy. His overall health has been declining over the past two months, and he spends most of his time in his favorite chair at home.

After a thorough evaluation, no immediate cause for his symptoms is identified. However, a CT pulmonary angiogram is performed, which reveals multiple pulmonary emboli. The scan also includes part of the upper abdomen, which shows no liver metastases.

What is the most appropriate management plan for this patient?

MRCP2-3725

A 67-year-old man with metastatic lung cancer presents with acute confusion and drowsiness. Upon admission, his corrected calcium level is found to be 3.13 mmol/l and he is immediately treated with IV fluids and 90 mg pamidronate. However, two days later, his confusion persists and he remains drowsy and constipated. A follow-up blood sample reveals a corrected serum calcium level of 3.05 mmol/l. What should be the next appropriate step in managing this patient?

MRCP2-3726

A 68-year-old man with metastatic lung cancer is admitted with upper back pain. It radiates around his chest ‘like a band’. He is having difficulty moving due to the pain. Neurological examination is normal and he has no bladder and bowel disturbance. An MRI spine is pending to determine if this is thoracic spinal cord compression. Currently, he is taking paracetamol 1 g qid and senna 2 tabs od. What medication should be initiated while waiting for the MRI results?

MRCP2-3727

A 68-year-old man with prostate cancer and widespread bony metastases presents with chest pain. He describes it as a ‘shooting’ pain which originates in his back but radiates forward in a band around his chest. This pain is associated with altered sensation affecting the skin at the level of his nipples.

He is currently taking paracetamol 1 g QDS, modified release morphine sulphate (MST) 30 mg BD, and oral morphine liquid 10 mg PRN. He is taking four doses of oral morphine liquid each day which he does not feel is helping his pain.

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