Archives: MRCP Part 2

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?

MRCP2-0896

A 64-year-old man presents to the hospital with a history of several months of weight loss, shortness of breath and a productive cough which was sometimes accompanied by haemoptysis. A chest x-ray had revealed apical consolidation and sputum was positive for acid-fast bacilli, leading to a diagnosis of tuberculosis. The patient has a past medical history of asthma and takes PRN salbutamol and Seretide inhaler twice daily.

One week after being diagnosed, the patient is admitted to the acute medical unit with shortness of breath and bilateral expiratory wheeze. His observations reveal a temperature of 37.1ºC, respiratory rate of 27 breaths per minute and oxygen saturations of 94% on room air. Oxygen is commenced via a face mask. A chest x-ray reveals the same apical consolidation as before, with no new features.

What is the most appropriate next step in his treatment?

MRCP2-0860

A 30-year-old office worker has been rushed to the emergency department after being rescued from a fire in her apartment. She has signs of smoke inhalation, with soot present in her nostrils and on the roof of her mouth. Her carboxyhaemoglobin level is 3%, and she has been experiencing a decreased level of consciousness since arriving at the hospital. There is no evidence of head trauma, and 600 μg of naloxone have not resulted in any improvement in her conscious level. You suspect that she may be suffering from hydrogen cyanide poisoning. Her blood pressure is 90/50 mmHg, with a pulse of 100/min and regular.

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

MRCP2-0861

A 32-year-old individual is brought in disoriented and bewildered. According to their acquaintances, they have a history of depression and have attempted suicide before. They were discovered with an empty container of phenobarbital, which they supposedly purchased online. Upon examination, they display symptoms of slurred speech, lack of coordination, and involuntary eye movements.
What treatment would be most effective in facilitating the removal of phenobarbital from their system?

MRCP2-0862

A 43-year-old woman is discovered unconscious by her partner after ingesting a bottle of amitriptyline tablets and a litre of vodka. Upon arrival at the Emergency department, her blood pressure is 100/60 mmHg, pulse is 100 and regular, and her Glasgow Coma Scale (GCS) score is 7. Her pupils are dilated and sluggishly reactive, and her chest and abdominal examinations are unremarkable. Venous blood gas analysis reveals a pH of 7.15 (normal range: 7.36 – 7.44), sodium level of 137 mmol/L (normal range: 137 – 144), potassium level of 4.3 mmol/L (normal range: 3.5 – 4.9), creatinine level of 122 μmol/L (normal range: 60 – 110), and bicarbonate level of 11 mmol/L (normal range: 20 – 28). As the anaesthetist prepares to intubate her, you observe several episodes of broad complex tachycardia. What is the best course of action for this patient?

MRCP2-0863

A 67-year-old man with a history of chronic obstructive airways, peripheral vascular disease, and congestive cardiac failure following a myocardial infarction is admitted to the hospital in atrial fibrillation with a fast ventricular response rate. His current medications include aspirin 75 mg, furosemide 80 mg, atorvastatin 10 mg, and amlodipine 5 mg, and he is using ipratropium, Seretide, and tiotropium inhalers. On examination, his pulse rate is 134 beats per minute and irregular, and his blood pressure is 140/65 mmHg. The jugular venous pressure is visible at the level of the clavicle, and the chest is clear to auscultation. What is the most appropriate first-line agent to use in order to control his atrial fibrillation?

MRCP2-0864

Ms K is a 50-year-old woman who has been referred to a neurologist for a possible diagnosis of Parkinson’s disease. She recently moved to the area to be closer to her family and joined a new GP practice. About a month ago, she noticed a slight tremor in her hands, which has since progressed. On her worst days, she struggles to hold a cup without spilling its contents.

Ms K was previously diagnosed with reversible obstructive airways disease after a lower respiratory tract infection and was prescribed a salbutamol inhaler. She also takes ciclosporin following a liver transplant a year ago due to cirrhosis of the liver from an unknown cause.

What is the most appropriate treatment for this patient?

MRCP2-0865

A 20-year-old woman is discovered unconscious at her residence after an argument with her partner. She experiences a seizure while being transported to the hospital and is admitted to the emergency department. Upon arrival, she is unresponsive and has dilated pupils. The following tests are available:

12-lead ECG: sinus tachycardia with widened QRS complexes.
pH 6.9 kPa (7.36-7.44)
pO2 35.6 kPa (11.3-12.6)
pCO2 7.2 kPa (4.7-6.0)
HCO3 12 mmol/L –
BE −15 mmol/L (± 2)
Lactate 4.0 mmol/L (1-2)
Na 135 mmol/L (137-144)
K 3.5 mmol/L (3.5-4.9)
Cl 100 mmol/L (95-107)
Alcohol 25 mg/dL

What is the most probable diagnosis for this patient?

MRCP2-0866

A 42-year-old man presents to the outpatient department with tremor, heat intolerance, and weight loss. He has a history of atrial fibrillation and takes warfarin and amiodarone. He is a non-smoker and drinks 10 units of alcohol per week. Blood tests reveal elevated thyroid hormone levels and absent vascularity and gland destruction on a thyroid ultrasound. What is the most probable diagnosis?