Archives: MRCP Part 2

MRCP2-1286

A 36-year-old patient arrives at the emergency department via ambulance. Despite recently moving locally, she has not yet registered with a GP and has experienced a lapse in her supply of carbimazole for hyperthyroidism, which was diagnosed three months ago. She is currently in a very unwell state, reporting palpitations. Upon examination, she displays a raised JVP, bilateral crepitations upon auscultation, severe peripheral edema, and has become extremely breathless. Her temperature is 40.1 degrees C. Oxygen is administered. An ECG reveals a heart rate of 170 bpm in AF, while a chest X-ray shows pulmonary edema. What is the most appropriate immediate course of action?

MRCP2-1251

A 52-year-old male presents at the diabetic clinic for his annual review. He has been diagnosed with diabetes and mild hypertension for four years and is currently taking gliclazide 160 mg bd, metformin 500 mg bd, rosuvastatin 10 mg od, and bendroflumethiazide 2.5 mg daily. During the consultation, he expresses concern about his deteriorating impotence, which has been ongoing for the past 12 months. Despite trying Viagra, he has not experienced any improvement. His wife is understanding, but he is becoming increasingly distressed about the situation. Upon examination, he has a BMI of 29 kg/m2, a blood pressure of 134/78 mmHg, and a pulse of 90 bpm. There is no evidence of neuropathy or retinopathy, and all pulses are palpable. He reports no history of joint pains.

The patient’s investigations reveal a HbA1c of 63 mmol/mol (20-46), fasting plasma glucose of 9 mmol/L (3.0-6.0), total cholesterol of 4 mmol/L (<2.5), serum testosterone of 6.5 nmol/L (9-35), plasma lutenising hormone of 0.5 mU/L (1-10), plasma follicle stimulating hormone of 0.9 mU/L (1-7), and plasma prolactin of 322 mU/L (<360). What further investigation would you recommend for this patient?

MRCP2-1252

A 54-year-old man presents to clinic after routine blood tests revealed a K+ level of 2.8 mmol/l. He has a history of angina and renal stones but reports feeling well. On examination, his chest is clear and abdomen is soft and non-tender. His vital signs are within normal limits and his ECG shows normal sinus rhythm. Further investigations reveal a urinary K+ level of 26 mmol/l (normal <20) and a creatinine level of 117 µmol/l. What is the most likely cause of his hypokalaemia?

MRCP2-1253

A 20-year-old man with a history of asthma presents to the Emergency Department with complaints of leg weakness and inability to walk after running a marathon the previous day. Upon examination, there is bilateral 3/5 weakness of the leg extensors. However, tone, reflexes, and coordination are unimpaired, and plantars are downgoing bilaterally. The straight leg raise and sensation to light touch and pain stimulus are unimpaired.

The blood tests reveal the following results: Hb 13.4g/dl, WBC 6.2 x 109/l, Na+ 136 mmol/l, K+ 2.9mmol/l, Urea 6.8 mmol/l, and Creatinine 104µmol/l.

What is the most appropriate treatment for this patient?

MRCP2-1254

A 75-year-old man is admitted with severe diarrhoea. He reports having profuse diarrhoea for the past 5 days. He denies any blood or mucous in his stools. During examination, he appears to be peripherally shut down, with a blood pressure of 90/50 mmHg and a heart rate of 120 beats per minute. The following blood results are obtained:

– Hb: 130 g/l
– Na+: 110 mmol/l
– Platelets: 500 * 109/l
– K+: 3.1 mmol/l
– WBC: 15.2 * 109/l
– Urea: 19.5 mmol/l
– Neuts: 11.2 * 109/l
– Creatinine: 215 µmol/l
– Lymphs: 2.0 * 109/l
– CRP: 80 mg/l

The patient is diagnosed with hypovolaemic shock and is resuscitated with 0.9% saline boluses.

Later in the day, the patient presents with muscle weakness. Upon examination, spastic quadriparesis is noted.

What is the most likely cause of the patient’s symptoms?

MRCP2-1255

You are asked to assess a 36-year-old man who has just had a seizure on the Acute Medical Unit. He was admitted two days ago due to acute agitation in the Emergency Department. The patient reported a 10-year history of alcohol overuse and had not consumed any alcohol for 24 hours after a disagreement with his girlfriend. Prior to this, he had been drinking 4-6 litres of cider per day along with varying amounts of spirits. He was admitted for detoxification and given chlordiazepoxide, pabrinex, and fluids. He has no other medical history.

The nursing staff reports that the patient has not had any other seizures during this admission and has been consuming small amounts of food and drink today. However, he has been experiencing generalized body pain and became confused 2-3 hours ago. The seizure is tonic-clonic and self-terminates after 3 minutes.

Upon examination after the seizure, the patient is drowsy but responsive to voice. His oxygen saturation is 100% on 15 liters of oxygen via a non-rebreather mask, and his temperature is 37.2 ºC. His heart rate is 110 beats per minute, and his blood pressure is 126/72 mmHg. His chest is clear, abdomen is soft and non-tender, and there is no focal neurology.

You order repeat blood tests and arterial blood gas. What electrolyte abnormality is most likely to have caused his seizure?

MRCP2-1256

A 70-year-old man is admitted onto the ward with confusion. He has a past medical history of an ischaemic stroke 4 months ago. His drug history includes atorvastatin, ramipril and clopidogrel. He lives alone and has no package of care.

On examination, he has very poor mobility. His heart rate is 105 bpm and blood pressure 105/75 mmHg. His JVP is not visible.

Blood results are as follows:

Hb 138 g/l
Na+ 155 mmol/l
Platelets 340 * 109/l
K+ 4.9 mmol/l
WBC 12.2 * 109/l
Urea 12.6 mmol/l (6.2 the previous month)
Neuts 8.4 * 109/l
Creatinine 115 µmol/l (58 the previous month)

What could be the possible reason for the hypernatraemia?

MRCP2-1257

A 44-year-old woman visits her doctor with a lump in her neck. Following an examination and initial tests, she is urgently referred to the local endocrine multidisciplinary team, who conduct further scans and diagnose thyroid cancer. She subsequently undergoes a thyroidectomy, which is uncomplicated. However, she experiences a sudden onset of hoarseness in her voice post-surgery. What is the most suitable course of action now?

MRCP2-1258

A 45-year-old female is admitted with an overdose of gliclazide. She reports taking ten 40mg tablets about three hours ago following an argument with her partner. She has a medical history of type 2 diabetes mellitus, self-harm, and psychotic depression. Her medication list includes gliclazide and venlafaxine.

Upon examination, she appears sweaty and clammy, and her heart rate is 120 bpm. Her Glasgow coma score is 13 (M6, V4, E3). Her plasma glucose level is 3.5 mmol/l.

You administer 100 ml of 20% dextrose, which initially raises her blood glucose level to 5.5 mmol/l. However, it quickly drops back down to 3.2 mmol/l despite a continuous infusion of 20% dextrose.

What course of treatment will you provide?

MRCP2-1259

A 44-year-old man is referred to the Endocrinology clinic by his GP due to asymptomatic hypercalcaemia found on routine blood tests. He has a medical history of hypertension and is currently taking amlodipine, ramipril and chlorthalidone.

The following investigations were conducted:

– Na+ 141 mmol/L (135 – 145)
– K+ 4.4 mmol/L (3.5 – 5.0)
– Calcium 2.85 mmol/L (2.2 – 2.6)
– Urea 6.6 mmol/L (2.0 – 7.0)
– Creatinine 98 µmol/L (55 – 120)
– Parathyroid hormone 5.5 pmol/L (1.6 – 6.9)

Urinary calcium 30 mg/24h (100 – 300)

What is the most likely cause of hypercalcaemia in this patient?