A 32-year-old patient visits the endocrinology clinic with complaints of low energy, difficulty with erections and sexual desire. The GP referred him after a morning serum testosterone test showed low levels. The patient has a history of T1DM and has been experiencing symptoms of acid reflux for the past six months. His current medications include Levemir, Novorapid, omeprazole and metoclopramide. Although his capillary sugar levels have been normal, his prolactin levels are elevated. What is the most appropriate course of action?
MRCP2-2091
A 65-year-old man presents to the Emergency Department with profuse, foul smelling diarrhoea, abdominal pain and fever.
His medical history includes hypertension, gout and osteoarthritis. He usually has regular bowel habits and has not experienced any recent changes. He underwent an endoscopy for dyspepsia two weeks ago and was diagnosed with gastritis. He is currently taking amlodipine 5mg, omeprazole 20mg, simvastatin 20mg, and uses a salbutamol inhaler one puff as required. He has no known drug allergies. He recently returned from a business trip to Paris.
Upon examination, he appears unwell with a heart rate of 110 beats/min and regular, a blood pressure of 100/60 mmHg, oxygen saturations of 96% on air, and a temperature of 38ºC. He is peripherally shut down with a capillary refill time of 3 seconds. Abdominal examination reveals a distended and diffusely tender abdomen with guarding.
An abdominal X-ray shows a loss of bowel wall architecture and thumb-printing consistent with the diagnosis. An erect chest x-ray shows clear lung fields with no air under the diaphragm.
What is the most likely cause of his symptoms?
MRCP2-2092
A 55-year-old man with a history of alcoholic liver disease is exhibiting confusion on the ward, as noted by the nursing staff. Upon examination, his heart rate is elevated at 100 beats per minute, but his blood pressure remains stable at 122/85 mmHg. Although he is alert, his family reports a change in his mood and behavior. Abdominal examination reveals general tenderness and ascites. Based on these findings, what is the severity of this patient’s hepatic encephalopathy?
MRCP2-2093
A 48-year-old woman presents to the hospital with a 6-day history of fever, anorexia, malaise, and abdominal pain. She has a past medical history of depression and a long-standing problem with alcohol abuse.
Upon examination, the patient appears jaundiced and unwell. Her vital signs include a temperature of 37.9ºC, a pulse of 106 bpm, and a blood pressure of 97/61 mmHg. Her chest is clear, but her abdomen is distended with tenderness in the right upper quadrant and evidence of shifting dullness on percussion. A hepatic bruit is also present.
Her blood work reveals a low hemoglobin level of 99 g/l, elevated bilirubin at 92 µmol/l, and a neutrophil count of 8.7 * 109/l. An ascitic tap shows a neutrophil count of 56 cells/mm³.
The patient is started on vitamin supplementation, nutritional support, and oral prednisone. However, after 7 days, she remains significantly jaundiced and has become increasingly confused. Repeat blood tests show worsening liver function with elevated bilirubin at 127 µmol/l and an INR of 2.3. Her Lille score is calculated as 0.52.
What changes should be made to her treatment plan?
MRCP2-2094
A 32-year-old woman was diagnosed with Crohn’s disease at the age of 25 years. She has been admitted to the hospital annually since her diagnosis with acute flare-ups necessitating systemic corticosteroid courses. She has no extra-enteric manifestations of Crohn’s disease, but she has a troublesome perianal fistula that necessitates frequent antibiotic courses. Due to her poor health, she is having difficulty maintaining regular attendance at work. What is the next recommended step to keep this patient in remission?
MRCP2-2095
A 32-year-old male presents to the gastroenterology department with symptoms suggestive of ulcerative colitis. He reports having 5 episodes of diarrhoea per day with small amounts of blood in his stool. He has been otherwise well and stable, and does not require hospital admission. The patient was started on Pentasa, but reports no improvement in his symptoms. He is mildly dehydrated, but haemodynamically stable with a blood pressure of 120/76 mmHg and a heart rate of 70 beats per minute. On examination, his abdomen is soft and not distended. What is the most appropriate management?
MRCP2-2096
A 70-year-old man presents to the hospital with a three-day history of abdominal pain on the right side and vomiting. He has a medical history of peripheral vascular disease, chronic obstructive pulmonary disease, and ischaemic heart disease.
Upon examination, the patient appears unwell with a temperature of 38.5ºC, heart rate of 120 beats per minute, respiratory rate of 24 breaths per minute, and blood pressure of 90/60 mmHg. The patient also appears jaundiced, and tenderness is noted over the right upper quadrant on palpation.
Blood tests reveal the following results: Hb 115 g/l, Platelets 650 * 109/l, WBC 24.3 * 109/l, Neuts 20.5 * 109/l, CRP 348 mg/L, Na+ 146 mmol/l, K+ 5.8 mmol/l, Urea 10.5 mmol/l, Creatinine 190 µmol/l, Bilirubin 225 µmol/l, ALP 894 u/l, ALT 160 u/l, γGT 279 u/l, and Albumin 27 g/l.
An urgent ultrasound of the abdomen reveals sludge in the gallbladder and a dilated common bile duct at 13mm. The spleen and kidneys appear normal. The patient is fluid resuscitated and started on piperacillin-tazobactam after blood cultures are taken. After six hours of treatment, the patient’s blood pressure improves to 130/70 mmHg, heart rate decreases to 95 beats per minute, and the patient is passing 50 millilitres of urine an hour.
What is the next appropriate management for this patient?
MRCP2-2097
A 16-year-old male presents with a 4-month history of PR bleeding, lower abdominal pain and left jaw pain. He reports an inability to gain weight and appears ‘skinnier than his friends’. He has no other medical history. He knows his father and uncle have ‘some problems with their bowels but they don’t talk about it’.
On examination, he has a body mass index of 14.5 kg/m² and abdomen is soft. PR is negative. Cardiovascular and respiratory examinations are normal. Limb neurological examination is unremarkable. However, when testing muscles of mastication, you note a raised bony mass in his left jaw that is tender in a non-cranial nerve distribution to palpation.
Colonoscopy reveals hundreds of polyps in his small bowel. What is the most likely diagnosis?
MRCP2-2098
A 50-year-old Caucasian man presents with an acutely painful right knee. He is unable to move due to the pain and swelling. Prior to this episode, the patient states that he is generally active, often enjoying a round of golf every Sunday. Last month he had a minor fall onto both knees whilst gardening. He puts his current symptoms down to general aches and pain of ‘getting older’.
The patient has also noticed that he is waking up more often in the night to urinate. His wife has noticed that he is looking more ‘bronzed’ despite them not going abroad on vacation this year. On further questioning, he admits to drinking 4-5 pints of beer per week. He is a non-smoker.
On examination on the Medical Assessment Unit you note significant right-sided knee swelling. The joint is hot and tender to touch. There is no evidence of any surrounding skin changes.
What is the most probable cause of his acutely swollen knee?
MRCP2-2099
The Emergency Medical Team was called in by the urology team for a 63-year-old man who had been admitted a few hours ago with complaints of haematuria and loin pain. A CT scan revealed the presence of renal calculi and he was being treated conservatively with intravenous saline hydration therapy, as well as intravenous paracetamol 1g QDS and IV morphine 10mg stat boluses when required. An hour ago, he complained of nausea and vomiting and was given metoclopramide 10mg IV bolus, which had a good response. However, in the last few minutes, he developed severe neck stiffness and was unable to open his eyelids, with a locked jaw and protruding tongue. He had a history of panic attacks, type 2 diabetes mellitus, hypertension, hypercholesterolaemia, chronic kidney disease stage 3, and osteoarthritis. His drug history included diazepam 2mg TDS PRN, metformin 500mg TDS, gliclazide 80mg OD, ramipril 5mg OD, atorvastatin 20mg ON, and naproxen 500mg BD PRN.
Upon examination, the man was acutely compromised, with his head fixed in a rotated position, protruding tongue, and locked jaw. His eyelids were closed, his back was arched, and his upper limbs were flexed while his lower limbs were extended. He was very distressed but was still able to sustain respiratory effort, with a respiratory rate of 32/min and oxygen saturations of 96% on air. His chest was clear to auscultate, and cardiovascular examination was unremarkable except for a tachycardia of 132 bpm. His blood pressure was 122/78 mmHg, and his temperature was 37.4ºC. Although he was unable to speak, he seemed to be fully alert, and his capillary blood sugar was 8.2.
The immediate next best management step would be to secure intravenous access and attach a 15 litre/min non-rebreather oxygen mask since the patient did not tolerate a Guedel airway insertion. What is the next single best immediate management step?