A 48-year-old woman has been referred to the Cardiology Clinic by her GP for an opinion on atrial fibrillation. She has been experiencing increasing fatigue for the past few months and was diagnosed with AF by her GP. During examination, she presents with a small-volume pulse, DJV, left parasternal lift, a tapping apex impulse, and a loud first heart sound accompanied by a mitral early- to mid-diastolic murmur. Additionally, there seems to be a mid-diastolic tricuspid murmur. What is the appropriate diagnosis for this clinical presentation?
MRCP2-2187
A 75-year-old man was brought to the hospital after collapsing. A caregiver at his nursing home reported that he became pale and unresponsive in a chair but regained consciousness after a few minutes. The patient has a medical history of hypertension, hypothyroidism, mild dementia, and a previous seizure 10 years ago.
Upon examination, the paramedics noted a heart rate of 34/min, which has since resolved. The patient’s heart sounds are normal, capillary refill is 3 seconds, and his pulse is regular at 60/min. Which medication(s) could have caused the collapse?
MRCP2-2188
A 70-year-old man with memory problems attended a specialist memory clinic with his son. His son was very concerned and mentioned that his father had been much more forgetful over the past year. He had left the front door open and occasionally got lost when he drove to the grocery store. On one occasion he had been found by a police officer wandering the streets in his pajamas.
This man had a family history of Alzheimer’s disease with both his father and brother being diagnosed with the condition in their seventies.
On examination he had a Mini Mental State Examination Score of 20/30. Otherwise a full physical examination was unremarkable.
Magnetic resonance of imaging of the brain showed marked atrophy of the medial temporal lobes bilaterally with no evidence of a reversible cause of dementia.
You suspect that this man has Alzheimer’s disease and wish to start him on donepezil.
Before starting him on this medication which of the following should you arrange?
MRCP2-2189
A 70-year-old man is admitted to the hospital with confusion. He has a medical history of hypertension, Parkinson’s disease, and hypercholesterolemia. He takes co-careldopa, amlodipine, and atorvastatin. He lives alone and is independent.
Vital signs:
Heart rate: 101 beats per minute Blood pressure: 120/77 mmHg Respiratory rate: 20/minute Oxygen saturations: 97% on room air Temperature: 37.8ºC
During the examination, suprapubic tenderness is noted. The Glasgow coma scale is 14/15.
The patient is treated with antibiotics for a presumed urinary tract infection. Although he clinically and biochemically improves, he remains confused after 3-4 days of admission. Other causes of delirium are ruled out. He becomes increasingly agitated and poses a risk to himself and other patients, despite conservative measures to re-orient him.
What is the most appropriate medication choice given the patient’s clinical history?
MRCP2-2190
An 80-year-old woman is admitted to the acute medical unit with abdominal pain, swelling and confusion. She has a medical history of Parkinson’s disease, recurrent urinary tract infections and hypertension. She is currently taking amlodipine, co-careldopa and doxazosin. She resides in a care home and is usually pleasant and talkative with no history of memory problems. However, her behavior is out of character. Her observations are heart rate 88 beats per minute, respiratory rate 18/minute, oxygen saturations 97% on room air, blood pressure 145/88 mmHg and temperature 37.1ºC.
Upon examination, impacted faeces in the rectum and mild suprapubic tenderness are noted. She is inattentive and confused, and her cognition fluctuates. A unilateral resting tremor and mild bradykinesia are also observed. Urinalysis showed leucocytes +++ and nitrites +. An ECG is unremarkable. Blood tests reveal elevated CRP levels, but they normalize after treatment with antibiotics for a presumed urinary tract infection and laxatives and suppositories for constipation.
Despite these interventions, the patient remains confused, agitated and inattentive, posing a danger to herself and other patients on the ward. Given the likely diagnosis, what is the most appropriate pharmacological management?
MRCP2-2191
A 75-year-old man is receiving hospital care for a urinary tract infection. Initially, he was disoriented, but his condition has since improved. However, his daughter reports that his short-term memory has declined over the past five months, and he is experiencing visual hallucinations.
During the physical examination, his respiratory rate is 16 breaths per minute, and his oxygen saturation is 95% on air. His heart rate is 69 beats per minute, and his blood pressure is 121/80 mmHg. He is warm and well-perfused, and his abdomen is soft and non-tender. His Glasgow coma score is 14 due to confusion for voice, and he has a normal neurological examination except for mild rigidity. He is afebrile at 36.6ºC.
Which medication is most likely to alleviate his ongoing symptoms?
MRCP2-2157
A 28-year-old male is admitted to the gastroenterology ward with a flare up of his Crohn’s disease. He has a one week history of passing loose stools, up to 7 times per day, alongside severe generalised abdominal pain and fevers. His observations are as follows: heart rate 98/min, blood pressure 116/80 mmHg, respiratory rate 18/min, SpO2 99%, Temperature 38.1ºC.
Blood results reveal the following: CRP 105 mg/L
He is currently being treated with IV hydrocortisone, which he has taken for 6 days with no improvement in symptoms.
What is the next step in management to consider for this patient?
MRCP2-2158
A 30-year-old male patient presents with acute severe ulcerative colitis. He has been experiencing frequent episodes of bloody diarrhoea and abdominal pains. Despite being on a reducing dose of steroids at home, he failed to respond. After 5 days of treatment with intravenous hydrocortisone, he developed tachycardia, hypotension, and worsening abdominal pain.
What is the most appropriate next step in the investigation?
MRCP2-2159
An 82-year-old man complains of worsening fatigue and generalized bone pain over the past few months. He is mostly confined to his home due to his frailty. The patient has a history of COPD and osteoarthritis.
During the examination, the patient displays moderate proximal muscle weakness and a waddling gait. X-rays of the femurs reveal pseudofractures, and the results of blood tests are still pending.
What is the most probable underlying cause of the patient’s symptoms?
MRCP2-2160
A 40-year-old restaurant owner presents to the gastroenterology clinic with complaints of chronic diarrhoea that is difficult to flush away, along with anorexia and epigastric abdominal pain over the past few months. He reports a weight loss of 8 kg over the past year. He is a non-smoker and drinks at least 30 units of alcohol per week. On examination, he has spider naevi on his chest and abdomen, but no abdominal masses. His BMI is 22 kg/m², blood pressure is 100/82 mmHg, and pulse is 80 beats per minute and regular.