Archives: MRCP Part 2

MRCP2-2192

A 65 year old man presents with a 9 month history of abnormal behaviors which have been noticed by his daughter. He has described seeing vivid visual hallucinations of animals in his living room which sometimes talk to him and appear very real. He believes that he is a zookeeper and is responsible for taking care of the animals although this is not true.

At times he is lucid and is fully independent but at other times he is disorientated in time and place and is unable to perform simple tasks such as preparing food and going to the shops. His daughter thinks that his mood is also lower since the onset of symptoms. He presented in A+E today because of having a second fall in two weeks.

There is no history of infective symptoms. He went to see his GP three days ago who thought that he may have a UTI and prescribed trimethoprim.

He has a history of stroke 8 years ago and hypertension and takes warfarin, amlodipine and enalapril.

Physical examination is unremarkable except for slightly increased tone on the left side compared to the right.

Bloods:

Hb 14.5 g/dl
Platelets 400 * 109/l
WBC 11.8 * 109/l

Na+ 140 mmol/l
K+ 4.4 mmol/l
Urea 5.9 mmol/l
Creatinine 80 µmol/l

Bilirubin 5 µmol/l
ALP 60 u/l
ALT 18 u/l
Calcium 2.40 mmol/l
Albumin 42 g/l

MSU (from GP from 3 days ago): Heavy growth of E.coli Sensitive to trimethoprim, nitrofurantoin, amoxicillin and co-amoxiclav

CT Brain: some generalised atrophy and periventricular white matter changes normal for age. Changes in keeping with an old left sided lacunar infarct

Mini Mental State Examination 16/30

Which medications would most appropriately treat the underlying diagnosis?

MRCP2-2193

A 70-year-old man is hospitalized with community-acquired pneumonia. He is experiencing increasing confusion and visual hallucinations of children playing in the ward, particularly at night. There are no other apparent neurological or psychiatric symptoms, and no history of dementia. What test should be performed to confirm the underlying cause of his confusion?

MRCP2-2194

A 56-year-old male is brought into your outpatient clinic by his daughter. The patient seems confused and disoriented, and his daughter reports a history of increasing forgetfulness and odd behavior over the past 9 months. She has noticed that he has become more withdrawn and has difficulty with social interactions. He often repeats the same phrases over and over again, and his behavior has become inappropriate at times. For example, he recently urinated in public without realizing it was inappropriate. Last week, he gave his daughter a headstone for her birthday, which she found disturbing. On examination, he continues to repeat the phrase ‘What’s up doc?’ and seems unaware of his surroundings.

MRCP2-2195

A 72-year-old male has been diagnosed with moderate to severe Alzheimer’s disease, following a two-year gradual cognitive decline. Despite initially attributing it to aging, his family now recognizes the need for nursing home care. His MMSE score is 7/30. He has a history of previous myocardial infarctions but has not reported chest pain recently. His ECG shows no signs of ischemia and a PR interval of 290ms. What is the recommended treatment plan?

MRCP2-2196

You review a 75-year-old man who was admitted three days earlier with worsening confusion. According to his daughter he worsened overnight, becoming more agitated with slurred speech and a slight drooping of the left side of his face. He now no longer recognises her, and tried to hit her when she visited him on the ward earlier in the day. His BP is 120/80 mmHg, pulse is 70/min (AF), and he has a murmur consistent with aortic stenosis. There is slight drooping of the left side of his face, and some apparent coordination problems affecting the left hand side. The examination is cut short when he accuses you of stealing from him and tries to hit you. Routine bloods are unremarkable.
What is the most appropriate intervention in this case?

MRCP2-2197

A 72-year-old man visits the memory clinic accompanied by his wife. He retired from his job as a teacher about a year ago due to difficulty in keeping up with the workload. His wife has noticed a decline in his short-term memory over the past several months. He frequently misplaces items around the house, and she discovers things in unusual locations in the kitchen. When confronted about this, he becomes agitated. He has been experiencing disturbed sleep, waking up early in the morning and sleeping during the day. He has no significant medical history except for hypertension, which is being treated with ramipril 5 mg. He appears somewhat disheveled.
During a general physical examination, his blood pressure is 132/82 mmHg, and there are no significant findings. He has some memory impairment, with a mini-mental state examination score of 20/30. Routine blood tests are normal, and an MRI indicates underlying Alzheimer’s disease.
What is the most appropriate course of action?

MRCP2-2198

A 90-year-old woman is brought in by her son as her memory has been deteriorating over the past year. Upon clarification with her son, it is confirmed that the patient has deteriorated over many months and has not had an acute illness. She has no significant past medical history apart from an appendicectomy when she was a teenager.

On examination, the patient is comfortable at rest, has a temperature of 36.8 degrees Celsius, heart rate of 70 beats per minute and blood pressure of 115/90 mmHg. Besides haematology and biochemistry, what other tests should be included in her initial screen?

MRCP2-2199

An 80-year-old man with myelofibrosis presents with a haemoglobin level of 67 g/l upon admission. After receiving two units of red cells, he is discharged three days later. However, he is readmitted six days later with fever and jaundice. His blood tests reveal a Hb level of 71 g/l, Na+ level of 137 mmol/l, and Bilirubin level of 39 µmol/l, among others. What is the best course of action for managing this condition?

MRCP2-2200

A 35-year-old painter visits a new GP for a routine check-up. Past medical history of note includes a recent diagnosis of eczema. Some blood tests are ordered, and the GP contacts you to discuss the results. The clinical examination was unremarkable.
The investigations reveal the following:
Haemoglobin (Hb) 110 g/l 135–175 g/l
Mean corpuscular volume (MCV) 70 fl 76–98 fl
White cell count (WCC) 4.5 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 200 × 109/l 150–400 × 109/l
Ferritin 280 µgl/l 20–250 µg/l
Hb electrophoresis Normal
What is the most likely diagnosis?

MRCP2-2175

A 25-year-old man presents to you with symptoms of severe depression. He reports feeling anhedonic and has experienced a loss of appetite over the past 6 months. Prior to this, he was a high-achieving individual with a large social circle. He has no known medical conditions, but his father has a history of bipolar disorder. He denies any substance use.
During the examination, he avoids eye contact and appears expressionless. He reports experiencing second-person auditory hallucinations for the past 4 months. His handwriting is small and cramped, and he has a slow gait with increased tone in his left arm.
Laboratory investigations reveal the following results:

Albumin 40 g/l 35–55 g/l
Alanine aminotransferase (ALT) 25 IU/l 5–30 IU/l
Alkaline phosphatase (ALP) 90 IU/l 30–130 IU/l
Bilirubin 15 μmol/l 2–17 µmol/l
What is the most likely diagnosis?