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?
MRCP2-2170
A 56-year-old man has been experiencing intermittent lower back and right knee pain and diarrhoea for the past year. He previously underwent investigations for diarrhoea, which revealed non-specific inflammation in the ascending colon. He has lost 3 kg in weight over the past 18 months, drinks occasional alcohol, and smokes 10 cigarettes per day. Cardiovascular and abdominal examination is normal, but tenderness is present over the sacroiliac joints and a small right knee effusion is noted. Blood tests show a low haemoglobin level, high mean corpuscular volume, elevated erythrocyte sedimentation rate, and normal electrolyte and liver function tests. What is the most likely diagnosis?
MRCP2-2171
A 44-year-old man presents to neurology outpatients with a 2-month history of disinhibited behaviour. His family reports that he has been urinating in public and has been brought home by the police twice recently. He has also been experiencing weight loss over the past year, going from 110 kg to 92 kg. He complains of pain in his lower back, right knee, and left ankle, and has been having diarrhea that is difficult to flush and smells bad.
On examination, he appears pale and has angular cheilitis. His abdomen is distended with some shifting dullness, but no palpable organomegaly is present. He has a positive palmo-mental reflex, and his right knee and left ankle are swollen with minimal tenderness and good range of motion.
Lab results show a low albumin level, low hemoglobin, and an elevated platelet count. A CT scan of the brain is normal, but a duodenal biopsy reveals expanded villi containing macrophages staining positive with periodic acid–Schiff stain.
What is the most likely diagnosis?
MRCP2-2172
A 52-year-old man presents to the outpatient clinic with complaints of weight loss and abdominal pain for the past eight months. He describes the pain as generalised and associated with bloating. He has also noticed an increase in bowel frequency and loose stools. He has lost approximately 10 kg in weight despite having a good appetite. The patient has a history of intermittent knee pain and occasional night sweats. He is a non-smoker and consumes 30-40 units of alcohol per week. On examination, he is thin with diffuse abdominal tenderness and palpable lymph nodes in his neck, axillae, and groins. Investigations reveal low haemoglobin, low albumin, and negative stool culture. What is the most appropriate treatment for this patient?
MRCP2-2173
A 55-year-old woman has been diagnosed with Wilson’s disease. As you review her blood test results, which of the following would you anticipate finding in a patient with this condition?