Archives: MRCP Part 2

MRCP2-0886

A 32-year-old man is brought to the Emergency Department from a music festival. He is accompanied by a friend who tells you he has taken the street drug NRG-1. The patient is agitated and difficult to assess as he will not stay on the trolley. He is sweating profusely. Formal assessment is impossible but he is obviously confused and appears to be hallucinating.

Examination shows a heart rate of 139 bpm with a blood pressure of 158/105 mmHg. Heart sounds are rapid but with no murmurs. The chest is clear to auscultation and oxygen saturations are 99% on air but his respiratory rate is 36/min. He is globally hypertonic with marked clonus in the lower limbs. Tympanic temperature is 40.6°C.

Blood results show:

Haemoglobin 129 g/L Sodium 119 mmol/L Creatine Kinase 1895 ng/mL
Haematocrit 0.29 Potassium 5.5 mmol/L CRP 8.9mg/L
White cells 15.6×10^9/L Chloride 90 mmol/L
Neutrophils 11.7×10^9/L Urea 7.2mmol/L
Platelets 303×10^9/L Creatinine 100µmol/L

Urine is dilute but contains blood, protein and ketones on dipstick analysis

What is the most appropriate initial intervention for this patient?

MRCP2-0887

A 65-year-old woman presents to the Emergency department with an acute increase in serum creatinine. She has a medical history of Type 2 diabetes and is currently taking lisinopril, amlodipine, and indapamide, as well as metformin and simvastatin. Recently, she was prescribed trimethoprim for a UTI. Her blood pressure is 148/84 mmHg, and there are no signs of fluid overload.

Na+ 140 mmol/l
K+ 4.9 mmol/l
Urea 5.8 mmol/l
Creatinine 162 µmol/l
Creatinine (one month ago) 112 µmol/l

What is the most probable cause of the rise in creatinine levels?

MRCP2-0888

A 42-year-old man presents to the emergency department with complaints of breathlessness. He reports feeling lightheaded, developing a headache, and experiencing difficulty breathing while leaving a restaurant. An ABG done on admission shows carbon monoxide at 26%. He has a history of well-controlled asthma, smokes 15 cigarettes per day, and has a 23 pack-year history. He works as a teacher in central London. On examination, he is receiving 15L of oxygen via a non-rebreather mask, and his chest is clear on auscultation. Neurological examination is normal, and an ECG shows no ischaemic changes. His saturations are at 100%, respiratory rate at 16/min, blood pressure at 126/87 mmHg, heart rate at 84/min, and temperature at 36.8°C. What is the most appropriate management plan?

MRCP2-0889

An 80-year-old woman presents to the acute medical ward with a 3-day history of dysuria and right loin pain. The diagnosis of pyelonephritis is confirmed and she is treated with ceftazidime and intravenous gentamicin. After 8 hours of the dose, gentamicin levels are measured and the trough level is found to be 3.1 mg/L (1 – 2). What should be the next appropriate step in managing this patient?

MRCP2-0890

A 25-year-old female is brought to the Emergency Department from a beach day in Cornwall. While wading through the water, she suddenly felt a sharp pain in her left foot. She immediately stopped and noticed a small puncture wound on her foot. The pain became unbearable, and she was unable to walk.

On examination, the patient was anxious and had difficulty breathing. Blood pressure was 100/70 mmHg, pulse rate was 110/min, respiratory rate was 24/min, and she had swelling and discoloration around the site. During the evaluation, she complained of blurred vision and dizziness.

Which of the following is an important initial management step?

MRCP2-0891

A 44-year-old male was rushed to the Intensive Care Unit (ICU) as an emergency admission after experiencing complications during an elective open cholecystectomy under general anaesthetic. He had been successfully intubated and ventilated, but shortly after the operation began, his heart rate skyrocketed from a resting rate of 72 bpm to 142 bpm. His oxygen saturation levels dropped to 92% on 15 litres of oxygen per minute, and his blood pressure rose from his baseline of 114/78 mmHg to 162/98 mmHg. Despite several checks to ensure that the tracheal tube was correctly sited, his end tidal CO2 concentration continued to rise. The patient’s medical history was unremarkable except for an appendicectomy under general anaesthetic at the age of 26.

The surgery was immediately halted, and the patient was intubated and ventilated upon arrival at the ICU. He maintained an oxygen saturation level of 96% on 15 litres per minute of oxygen, but appeared flushed and had significant muscle rigidity. His blood pressure had risen to 174/102 mmHg, and his heart rate was 136 bpm. His temperature was 38.2 C. Upon examination, the cardiovascular system revealed vasodilated peripheries with a bounding pulse and normal heart sounds. Auscultation of the lungs revealed good air entry in all zones and a correctly cited tracheal tube. Examination of the abdomen was unremarkable. The neurological system examination confirmed the presence of equal and reactive pupils, with generalised muscle hypertonicity and masseter muscle spasm. A central venous catheter and arterial line were inserted, and the central venous pressure was 9 cm.

An arterial blood gas sample was taken on 15 litres of oxygen, revealing the following results:

pH 7.26
HCO3 18 mmol/l
Pa02 17 kPa
PaC02 7.6 kPa
Na+ 139 mmol/l
K+ 7.1 mmol/l

What is the most appropriate immediate management step?

MRCP2-0892

A 72-year-old woman returns to the Emergency Ward with confusion some two weeks after discharge post-hip replacement surgery. She made a relatively good recovery and was started on a range of medications, including an antidepressant, as she said she was feeling really very low after the surgery. She did have depression which required medication a few years earlier, and felt that her old symptoms were returning. Her daughter tells you that she has become increasingly forgetful over the past three to four days.

On examination, her blood pressure (BP) is 130/80 mmHg, her pulse is 72/min and regular. She is euvolaemic.

Investigations:

Haemoglobin 138 g/l 135–175 g/l
White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
Platelets 195 × 109/l 150–400 × 109/l
Sodium (Na+) 129 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 95 µmol/l 50–120 µmol/l

Which of the following medications is most likely to be responsible for her low sodium?

MRCP2-0893

A 32-year-old woman presents to the clinic for follow-up of her rheumatoid arthritis. She is currently on weekly methotrexate but is still experiencing active tenosynovitis in her wrists and small finger joints. She has expressed her desire to start a family soon but understands the importance of stabilizing her joint disease before becoming pregnant. Her routine blood work is normal.
What is the most suitable treatment plan during pregnancy?

MRCP2-0894

A 49-year-old man is admitted to the Medical Assessment Unit with a pneumonia. He has had a persistent cough for the past week despite taking amoxicillin prescribed by his GP.

His medical history includes alcoholic liver disease and a hepatic transplant 8 months ago, hypertension, and type II diabetes controlled by diet. He has been sober for the past 2 years and has never smoked. He is currently taking ramipril, simvastatin, and tacrolimus.

Upon admission, he has a temperature of 38.1 ºC and oxygen saturation of 94% on air. His heart rate is 110 beats per minute and blood pressure is 105/65 mmHg. Left basal crepitations are heard on auscultation, and a chest x-ray confirms a left lower lobe pneumonia.

The patient is started on intravenous fluids, 2 liters of oxygen via nasal cannulae, co-amoxiclav, and clarithromycin. His statin is withheld.

Two days later, the ward team is called to review the patient as he has developed limb twitching. During the assessment, he experiences a generalized tonic-clonic seizure that requires lorazepam to terminate it.

Which investigation is most likely to reveal the cause of his seizures?

MRCP2-0895

A 42-year-old construction worker is discovered in a distressed state after collapsing while handling chemicals on a job site. Upon arrival at the Emergency department, the patient is confused, experiencing excessive salivation, and has had an episode of urinary and fecal incontinence. The patient is also exhibiting noisy breathing, with a blood pressure of 90/60 mmHg and a pulse rate of 48 beats per minute.

What is the most suitable course of action in this situation?