A 15-year-old boy was brought to the Emergency department by his parents after being stung on the hand while fishing. He had been casting his line when he suddenly felt a sharp pain in his hand. On examination, there was a small puncture wound on the palm of his right hand with surrounding redness. His father, who had been fishing with him said that he had accidentally touched a small fish while baiting his hook and that this was the cause of the sting. He was a keen angler and recognised the fish as a weeverfish.
What is the recommended treatment for this patient?
MRCP2-0825
A 75-year-old male with a history of chronic obstructive airway disease presents to his primary care physician complaining of worsening shortness of breath. He reports feeling unwell for the past five days with a fever, persistent cough producing yellow/green sputum. Despite taking his home supply of prednisolone 30 mg for the past four days, he has not experienced any improvement. He has been using his home nebulizer in addition to his inhalers during exacerbations. Currently, he is taking two puffs of a Serevent and Flixotide combination inhaler twice daily, salbutamol 5 mg and ipratropium 500 mcg four times a day, and Uniphyllin Continus® 200mg twice daily. During the examination, the patient’s peak flow was measured at 210 L/min, and he exhibited widespread expiratory wheezing and coarse crepitations throughout all lung fields. Due to a previous allergy to penicillin, the patient was started on oral clarithromycin 500 mg twice daily. However, two days later, he began experiencing episodes of loose stools, abdominal pain, nausea, and vomiting. The patient was prescribed metoclopramide to alleviate his symptoms, which helped with vomiting but not nausea. After starting metoclopramide, the patient developed hand tremors and occasional palpitations, which he attributed to increased nebulizer use. What would be your next steps in managing this patient?
MRCP2-0826
A 49-year-old male presented with general fatigue and nausea. He denies having fever, vomiting, diarrhea, or any pains. He appeared dehydrated, but otherwise, observations and physical examination were within normal limits.
Looking back at past results from 3 weeks ago, his renal function was in the normal range.
He has a history of bipolar disorder, diet-controlled diabetes, and hypertension. He has been compliant with his lithium tablets and undergoing regular checks for the levels.
The patient revealed that his General Practitioner had recently started him on a new tablet 2 weeks ago.
What is the most likely precipitant for his symptoms?
MRCP2-0827
A 20 year old man is brought into the Emergency Room by his parents who are extremely worried about his condition. They explain that he came home from a night out with friends and started acting strangely. Upon speaking with him, he claims to be feeling euphoric and believes that he is an angel sent from God. He also mentions seeing music as colors emanating from the radio earlier in the evening. Although he denies any hallucinations, he describes colors as being more vivid and vibrant. He has been unable to sleep for the past 24 hours.
During the examination, the patient appears confused and disoriented but remains alert. His skin color is normal, and his central capillary refill time is less than 2 seconds with moist mucous membranes. His eye movements are normal, and there is no peripheral focal neurology. His heart rate is 115 sinus tachycardia, and his blood pressure is 174/98. Blood tests come back essentially normal, and his respiratory rate is 16. Although his pupils are dilated, they are responsive to light equally. While testing his eye movements, he reports seeing trailing colors, and when he closes his eyes, he sees after-images that persist for a few seconds. He repeatedly asks for glasses of water during the consultation and drinks them quite rapidly.
The patient’s mother reports that he has no prior medical history, and his mental state has been normal until today. He was well before leaving the house 6 hours ago this evening. There is a family history of depression, and he recently dropped out of university due to not achieving the required grades.
Towards the end of the consultation, the patient suddenly becomes very agitated and fearful, pointing at a wall and believing that he is being chased by a monster. His family is unable to comfort him or lessen his agitation.
What is the most appropriate course of treatment to administer at this time?
MRCP2-0828
A 54-year-old construction worker was brought into the Emergency Department by his colleague. Over the last few hours, he developed severe diarrhoea, passing 10 loose stools in the last four hours. He was also passing urine more frequently and on a couple of occasions was incontinent of urine. He also complained of feeling unwell with a headache and nausea and as well as a cough with white phlegm, and at times felt very short of breath particularly upon coughing. He denied the presence of chest pain. He had a past medical history of COPD, atrial fibrillation, depression and hypertension and his drug history comprised of Seretide 2 puffs BD, salbutamol PRN, digoxin 250 mcg OD, warfarin 2 mg OD, sertraline 150mg OD, diazepam 2mg BD PRN and amlodipine 5mg OD.
Examination revealed the presence of an unwell and unkempt gentleman. His heart rate was 46 bpm and regular, his blood pressure was 88/48 mmHG, his respiratory rate was 18, oxygen saturations 96% on air and temperature 35.7ºC. His BM was 3.8 mmol/l. Examination of his cardiovascular system revealed the presence of warm well perfused peripheries with normal heart sounds and a JVP of 3cm. Examination of his respiratory system revealed the presence of copious upper airways secretions but the absence of respiratory distress. Examination of his gastrointestinal system revealed the presence of excess salivation but was otherwise unremarkable. Examination of his neurological system revealed the presence of bilateral pupil constriction but otherwise no abnormalities and a GCS of 15.
He was promptly transferred to the resuscitation area and cannulated with 2 large bore cannulae. Stat intravenous saline 3 litres were promptly infused and an urgent medical consult was requested. Initial investigations revealed the following:
Of the following options which is the most appropriate curative management step?
MRCP2-0829
You are asked to review a 70-year-old man on the medical ward. He has malignant carcinoma of the lung and had a lobectomy five days ago. Despite being on enoxaparin since admission, he had developed a left-sided deep venous thrombosis (DVT). He tells you he had a similar problem five years ago and had to take ‘blood-thinning injections’ for several months.
On examination, he looks comfortable with no signs of respiratory distress. His oxygen saturations are 97% on room air and on auscultation he has decreased breath sounds in the left lower lobe.
What is the best course of action for managing this patient while he remains in the hospital?
MRCP2-0830
A 50-year-old man presents to the emergency department with haematemesis. He reports ingesting a toxic substance in an attempt to end his life. Upon examination, he displays nystagmus, ataxia, and ophthalmoplegia. His vital signs are heart rate 105 beats per minute, blood pressure 125/75 mmHg, respiratory rate 24 breaths per minute, temperature 37.2ºC, and SpO2 96% on air. Blood tests reveal abnormal levels of platelets, WBC, CRP, and creatinine. What is the recommended course of treatment?
MRCP2-0831
A 75-year-old man is admitted to the hospital with a productive cough and difficulty breathing. He is diagnosed with community-acquired pneumonia and promptly treated with IV fluids and antibiotics. Subcutaneous enoxaparin is initiated for venous thromboprophylaxis on the day of admission. Due to persistent hypotension and oliguria, he is transferred to the General Intensive Care Unit for inotropic support around 12 hours after initial presentation.
The patient has a history of ST elevation myocardial infarction, treated with primary percutaneous coronary interventions one year ago. He takes Aspirin, Clopidogrel, Ramipril, Bisoprolol, and Atorvastatin regularly. He has no known drug allergies and lives independently with his wife.
After stabilizing, the patient is discharged to a respiratory ward on day 3 of admission. However, routine blood tests on day 7 show a significant drop in platelet count compared to admission bloods. There is no evidence of venous thrombosis upon examination. Haematology is consulted, and further investigations are requested.
What additional investigation, if any, is necessary to confirm a diagnosis of heparin-induced thrombocytopenia?
Platelet count on admission: 189 x 10>3 / microlitre Platelet count on day 3: 156 x 10>3 / microlitre Platelet count on day 7: 87 x 10>3 / microlitre International normalized ratio on admission: 1.1 International normalized ratio on day 3: 1.3 International normalized ratio on day 7: 1.2 Heparin-induced thrombocytopenia antibodies: positive (moderate titre)
MRCP2-0832
A 15-year-old girl presents to the emergency admissions unit with a three week history of coordination problems. Her mother noticed that she is dropping things frequently and has difficulty using cutlery. She is an active student studying for her GCSEs and hopes to continue on to sixth form. On examination, she had an ataxic gait, mild tremor of both hands, mild dysarthria, bilateral rapid nystagmus on lateral gaze, bilateral dysdiadochokinesia, and exaggerated reflexes throughout but plantars were flexor. Investigations revealed abnormal liver function tests, elevated serum calcium, and high serum ferritin. A magnetic resonance imaging (MRI) scan was normal. What is the most likely diagnosis?
MRCP2-0833
A 67-year-old woman presents to the clinic with a complaint of progressive shortness of breath and swollen ankles over the past 3 months. She has a medical history of breast cancer treated with docetaxel, cyclophosphamide, trastuzumab, and radiotherapy, as well as rheumatoid arthritis managed with methotrexate. On examination, bilateral pitting oedema to the mid calves and coarse crepitations to the mid zones of the lungs are noted. An echo reveals biventricular failure with a left ventricle ejection fraction of 28% and no evidence of pericardial thickening. Based on this information, which therapeutic is most likely implicated?