Archives: MRCP Part 2

MRCP2-0867

A 44-year-old Asian woman with a past medical history of pulmonary tuberculosis presents to the Dermatology Clinic with a new rash. The rash first appeared four weeks ago and is affecting her arms, legs, and back. She recently completed a 6-month course of rifampicin, isoniazid, ethambutol, pyrazinamide, and pyridoxine. On examination, she has multiple annular, scaly lesions over her face, arms, legs, and back, with blistering at the margins of the lesions. Her observations are stable, and she has no palpable lymphadenopathy. Investigations show normal values for haemoglobin, white cell count, neutrophils, lymphocytes, platelets, sodium, potassium, urea, creatinine, and C-reactive protein. What is the most appropriate investigation to confirm the diagnosis?

MRCP2-0868

A 28-year-old woman, who is six weeks into her pregnancy, presents after taking an unknown amount of white tablets. She refuses to wait for the results of her initial blood tests and leaves the hospital. However, she returns a few hours later complaining of feeling dizzy. Her investigations are repeated, and her salicylate levels are found to be 3.5 mmol/l on the first sample and 1.5 mmol/l on the subsequent one.

Investigations:
FBC, U&E, LFT Normal
Initial ABG pH 7.5
pa(CO2) 2.5 kPa
HCO3– 26 mmol/l
Repeat arterial blood gas (ABG) following return:
pH 7.4
pa(CO2) 3.5 kPa
HCO3– 24 mmol/l

What metabolic abnormality is observed during the first presentation?

MRCP2-0869

A 32-year-old man was admitted to hospital for investigation of a 3-month history of excessive thirst and frequent urination. He had a history of asthma, which was well-controlled with medication, and no other medical problems. He smoked 5–10 cigarettes per day and did not drink alcohol. There was no relevant family history. Physical examination was unremarkable.

Investigations reveal the following:

Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Urea 4.8 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 80 μmol/l 50–120 μmol/l
Corrected calcium (Ca2+) 2.40 mmol/l 2.20–2.60 mmol/l
Glucose (fasting) 4.8 mmol/l < 7.0 mmol/l
Plasma osmolality 330 mosmol/kg 278–305 mosmol/kg
Urine osmolality 250 mosmol/kg 350–1000 mosmol/kg

The patient proceeded to a water deprivation test, the results of which are below:
Investigation Urine osmolality
After 10 hours of fluid deprivation 180 mOsmol/kg
After desmopressin administration 220 mOsmol/kg

What is the diagnosis?

MRCP2-0870

A renowned athletics coach recently expressed concern that some of the athletes had abnormally high red cell counts – a sign of using erythropoietin (EPO). He lamented the fact that EPO had been administered to some athletes by their former coaches outside the country and they actually took the drug unknowingly.

What is the most effective method of detecting EPO misuse?

MRCP2-0871

A 46-year-old man, known for begging outside the station, is brought to the Emergency Department by ambulance. He is unconscious and hyperventilating. The nurses inform you that he has a history of alcohol abuse, cataracts potentially related to previous methanol ingestion, and epileptic seizures that have led to multiple hospital admissions. On examination, his blood pressure is 100/70 mmHg, pulse is 100/min regular, and he has crackles on auscultation of both lung fields consistent with cardiac failure. He has nystagmus and does not respond when you try to wake him. There is no smell of alcohol. Investigations reveal abnormal results for haemoglobin, white cell count, platelets, sodium, potassium, creatinine, chloride, bicarbonate, pH, and glucose. What is the most likely diagnosis?

MRCP2-0872

A 60-year-old man visits his GP complaining of enlarged breast tissue that has been present for 8 weeks. He is feeling self-conscious as his clothes no longer fit properly. He denies any breast pain or nipple discharge. His medical history includes hypertension, depression, chronic back pain, and benign prostatic hyperplasia.
During the examination, the patient appears healthy, and all vital signs are normal. There is visible enlargement of breast tissue on both sides, but no tenderness or breast lumps on palpation.
The GP suspects that the patient’s medication may be contributing to his symptoms.
Which medication is most likely responsible for this patient’s presentation?

MRCP2-0873

A 28-year-old car mechanic with a history of episodic abdominal pain, anorexia, constipation, and intermittent nausea and vomiting for the past six months was admitted to a surgical unit for evaluation after a severe episode. He has also experienced weakness in his hands for the past three weeks, making it difficult to use his gadgets. A medical registrar examined him and found weakness in the distal muscles of his limbs, absent tendon stretch reflexes, and flexor plantar responses. The sensory system was intact. The following investigations were conducted: white cell count, haemoglobin, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, erythrocytes, fasting blood glucose, sodium, potassium, and urinalysis. Which of these investigations would confirm the suspected diagnosis?

MRCP2-0874

A 30-year-old man presented to the Emergency Department with a history of abnormal posturing of his torso and neck for the past few hours. He had a history of aggressive behaviour and had been involved in altercations with his colleagues. His family had taken him to a psychiatrist recently and he had started taking antipsychotic medication.

Upon examination, he was afebrile. His neck was in forced extension, there was arching of his back and his arms were internally rotated. There was extension of the elbows and wrists.

What is the accurate description of his clinical presentation?

MRCP2-0875

You are requested to assist in the management of a 25-year-old woman who has been brought to the Emergency Department by her family. Upon examination, she appears restless and disoriented, with dilated pupils, noticeable tremors, excessive sweating, and teeth grinding. Her heart rate is regular at 110 beats/min, and her temperature is 38.2°C. The patient’s deep tendon reflexes are hyperactive. There is no significant medical history, but her family reports that she has been struggling with depression for a while and recently had her medications adjusted by her primary care physician.

What is the probable diagnosis?

MRCP2-0876

A 22-year-old college student presents to the emergency department accompanied by his friends who are worried about his behavior. They found him urinating on the couch in the living room. During the examination, he appeared restless, sweaty, and had occasional muscle spasms.

Vital signs: heart rate 110 beats per minute, blood pressure 165/105 mmHg, temperature 37.9ºC.

Upon reviewing his medical history, it is noted that he is taking citalopram for depression and has recently been prescribed another medication.

Which medication is most likely responsible for his current symptoms?