Archives: MRCP Part 2

MRCP2-1505

A 67-year-old man presents to the medical admissions unit with increasing drowsiness and confusion. He was diagnosed with primary small cell carcinoma of the lung six months ago but declined chemotherapy. His past medical history includes chronic obstructive pulmonary disease, ischaemic heart disease, hypertension, hypercholesterolaemia, and depression.

His wife brought him to the Emergency Department after noticing his increasing drowsiness and confusion over the last few hours. He had been relatively well prior to this. His GP had prescribed Oramorph solution PRN for new onset generalised aches and pains four weeks ago. He had developed abdominal pain, which the GP attributed to opiate-induced constipation and prescribed lactulose 15 ml BD, providing partial relief. He had not experienced weakness, numbness, or speech impairment, and had taken the prescribed dose of oramorph. His current medications include oramorph solution 10mg BD, paracetamol 1g QDS, dihydrocodeine 60mg QDS, lactulose 15 ml BD, aspirin 75mg OD, atorvastatin 20mg ON, bisoprolol 2.5mg OD, Ramipril 2.5mg OD, and furosemide 40 mg OD.

On examination, the patient was drowsy with a GCS of 12 (E 3 M5 V4). His blood pressure was 102/68, heart rate 58 bpm, respiratory rate 10/min, oxygen saturations of 95% on air, and temperature 36.6ºC. Cardiovascular and respiratory systems were unremarkable. Examination of his central nervous system revealed normal sized pupils, and no focal neurological signs were found. There was no evidence of neck stiffness, and Kernig’s sign was negative. The patient was uncooperative with an abbreviated mental state examination.

Which investigation is most likely to provide a diagnosis of the underlying cause?

MRCP2-1506

A 28-year-old female presents with secondary amenorrhoea after discontinuing the oral contraceptive pill 8 months ago. She complains of frequent headaches and experiences difficulty standing up from a seated position or climbing stairs.

During the examination, milk was expressed from her breasts, and her visual fields showed bilateral defects in the upper outer quadrants.

The following laboratory results were obtained:
– Prolactin 1080 mIU/L (NR<360)
– FSH 0.1 IU/L (NR 1-11)
– LH 0.2 IU/L (NR 20-75)
– TSH 0.1 mIU/L (NR 0.3-6.0)
– T4 8 pmol/L (NR 10-25)
– 9am cortisol 20 nmol/L (NR 140-700)

A pituitary MRI revealed a 3 cm pituitary mass with tenting of the optic chiasm.

What is the next step in managing this patient?

MRCP2-1507

A 26-year-old woman presents to the hospital with increasing confusion. Her parents report a gradual history of weight loss, abdominal cramping, and lethargy. She has no medical history and takes no regular medications. She lives with her parents, and her mother has hypothyroidism while her father has hypertension controlled with bendroflumethiazide.

During the examination, she appears thin with cool skin and sunken eyes. Her capillary refill time is 3 seconds, and her mucous membranes are dry. Bilateral symmetrical vesicular breath sounds are heard during chest auscultation. Her abdomen is soft with normal bowel sounds. She has a Glasgow Coma Scale of 14 and no focal neurology.

Her test results show:

Hb 10.4 g/dL
MCV 90 fL
WCC 6.4 *10^9/l
Platelets 170 *10^9/l

Na+ 105 mmol/L
K+ 5.8 mmol/L
Ur 8.8 mmol/L
Cr 90 µmol/L
Glucose 3.9 mmol/L

Urinary Osmolality 108 mmol/L
Urinary Sodium 67 mmol/L

Chest X-ray is clear, and CT Head shows no intracranial abnormalities.

What is the most probable diagnosis?

MRCP2-1508

A 22-year-old female presents to the emergency department with severe abdominal pain, vomiting, and lethargy. She reports feeling generally unwell for the past six months, during which time she has lost 12 kg in weight and has been constantly fatigued. Her mother and sister have hypothyroidism and take thyroxine. One month ago, she was diagnosed with hypothyroidism and started on levothyroxine 50 mcg daily. On examination, she appears unwell and dehydrated, with a pulse of 105 beats per minute and blood pressure of 70/40 mmHg. Her temperature is 37.6ºC and BMI is 19 kg/m². Cardiovascular, respiratory, and abdominal examinations are unremarkable. Previous investigations showed Hb 9.5 g/dl, MCV 105 fl, platelets 190 * 109/l, WBC 4.5 * 109/l, serum free T4 8.5 pmol/l, and serum TSH 5.5 mU/l. While awaiting new investigations, what is the most appropriate immediate treatment for this patient?

MRCP2-1509

You are asked to assess a 42-year-old man who has developed a fever and tachycardia after undergoing surgery. He is previously healthy, a non-smoker, and drinks alcohol only occasionally. The patient had a fall the previous night resulting in a distal radius fracture and underwent open reduction and internal fixation under general anesthesia. During the procedure, he received 4mg ondansetron and 8 mg dexamethasone for postoperative nausea and 10mg morphine for pain relief. He denies feeling unwell and has no symptoms suggestive of an intercurrent infection.

Upon examination, the patient’s heart rate is 130 beats/min and irregular, his blood pressure is 135/74 mmHg, and his temperature is 39.4ºC. His chest is clear to auscultation, his abdomen is soft and non-tender, and there is no rash or meningism. His right forearm is in plaster, but is not particularly painful, and his fingers are warm with normal sensation.

Lab results show Hb 130 g/l, platelets 460 * 109/l, WBC 10.5 * 109/l, Na+ 138 mmol/l, K+ 4.1 mmol/l, urea 5.1 mmol/l, creatinine 95 µmol/l, C-reactive protein 1 mg/L, thyroid stimulating hormone <0.02 mIU/L, and cortisol 45 µg/dL. What is the most appropriate initial treatment?

MRCP2-1510

A 23-year-old female presents with a 10-week history of nausea, constipation, and fatigue. She has no past medical history and takes no regular medications. Blood tests reveal a hemoglobin level of 110 g/l, platelet count of 422 * 109/l, and white blood cell count of 8.2 * 109/l. Thyroid function tests show normal TSH levels but elevated total T4 levels. What further investigation would you recommend?

MRCP2-1511

A 35-year-old man presents to the ED with a severe headache after chasing a car thief. He has a history of normal health and stature, but is found to be hypertensive with a BP of 165/90 mmHg, which later settles to 155/85 mmHg. Upon further questioning, it is discovered that his mother passed away at an early age from thyroid cancer, and his GP found elevated calcium levels of 2.84 mmol/l during routine blood work after he moved house a few months ago. What is the likely underlying diagnosis for his symptoms?

MRCP2-1512

A 25-year-old woman presents to the hospital after collapsing while shopping. Upon examination, her temperature is 37.2°C, her pulse rate is 78 per minute and regular, and her blood pressure is 164/92 mmHg. Heart sounds 1 and 2 are present with no added sounds, and her chest is clear on auscultation. Her abdomen is soft and non-tender with no organomegaly. Neurological examination is unremarkable. She has no significant medical history and is not taking any regular medications.

Further blood tests reveal low renin and aldosterone levels, hypokalaemia, and a serum bicarbonate of 30 mmol/l.

What is the most appropriate treatment for her condition?

MRCP2-1513

A 28-year-old female presents to the Emergency Department after collapsing without any warning signs. She reports waking up on the ground, face down. She has been experiencing general weakness, dizziness, and intermittent palpitations, which she recently discussed with her GP. Her medical history includes hypothyroidism and rheumatoid arthritis, which were previously managed with infliximab. Three months ago, she was diagnosed with TB, and she is currently taking methotrexate, folic acid, levothyroxine, artificial tears, rifampicin, and isoniazid.

During the examination, the patient complains of recurrent palpitations, and the cardiac monitor shows broad-complex tachycardia. Her blood pressure is stable at 117/68 mmHg, and she is given a bolus of amiodarone. Her venous blood gas reveals metabolic abnormalities, including a pH of 7.31, pCO2 of 4.3 kPa, and HCO3 of 15.6 mmol/l, among others. Additional investigations, such as a urine dipstick and chest and abdominal X-rays, are requested.

What is the most likely cause of the patient’s metabolic abnormalities?

MRCP2-1514

A 16-year-old girl comes to the clinic complaining of amenorrhea. She reports that she has never experienced a menstrual cycle. During the examination, you observe minimal axillary and pubic hair growth. Additionally, there are bilateral swellings in the groin area.

The blood test results are as follows:

– Testosterone: 11.2 nmol/L (< 1.8)
– FSH: 16 IU/L (1.8 – 22.5)
– LH: 120 IU/L (1.2-103)

Based on these findings, what is the most probable diagnosis?