Archives: MRCP Part 2

MRCP2-0807

A 32-year-old man presents to the emergency department at 3 am on Sunday morning in a state of extreme agitation. He appears alert from the end of the bed, tremulous and sweating profusely. His respiratory rate is 28 breaths per minute, oxygen saturation 96% on air, heart rate 136 beats per minute, blood pressure 190/105 mmHg and temperature 38.5ºC. Bilateral air entry is heard on auscultation of the chest with vesicular breath sounds. His peripheries are warm and clammy, and his pulse is fast and bounding. Heart sounds are normal with no added murmurs. JVP is not raised. He is talking but confused. Pupils are equal and reactive to light but markedly dilated. No lateralizing neurology is observed.

The nurse obtains a blood sample from the patient.

The initial investigation results are as follows:

ECG shows sinus tachycardia, with 1mm T wave inversions in V2-V6
Urine dipstick shows + protein +++ haemoglobin

Venous blood gas:

pH 7.32 7.31-7.41
pO2 5.35 kPa 4.0-5.3 kPa
pCO2 4.73 kPa 5.5-6.8 kPa
Lac 3.2 mmol/L <2.0 mmol/L
Glucose 6.4 mmol/L 4.0-7.8 mmol/L
HCO3 24 mmol/L 23-29 mmol/L
BE -3 -2 – +2

What is the most appropriate next step in management?

MRCP2-0808

A 25-year-old female patient is being evaluated after being admitted for an overdose of paracetamol. She consumed 25 grams of paracetamol and was initiated on N-acetylcysteine as her paracetamol level was 812 micromol/L eight hours after ingestion. She reports feeling fine and has no abdominal pain or other symptoms. When is it appropriate to discontinue N-acetylcysteine treatment?

MRCP2-0809

A 25-year-old intravenous drug user visits the Sexual Health Clinic for a routine check-up. During syphilis screening, the TPHA test comes back positive while the RPR test is negative. The patient claims to have never been treated for syphilis before and is given a course of IM procaine penicillin by a nurse in the clinic. However, shortly after receiving the injection, the patient becomes extremely agitated and starts throwing objects around the room. He appears to be experiencing visual hallucinations and cannot be reasoned with, eventually requiring restraint by security staff.
What could be the reason for this sudden change in behavior?

MRCP2-0810

A 50-year-old man arrives at the Emergency Department following an overdose, but he is unsure which of his regular medications he has taken too much of. He has a medical history of Crohn’s disease, hypertension, gout, depression, gastroesophageal reflux disease, and paroxysmal atrial fibrillation. The patient is experiencing chest pain and shortness of breath, and his vital signs are as follows: respiratory rate of 26/min, oxygen saturation of 94% on air, heart rate of 50/min, blood pressure of 75/40 mmHg, and temperature of 37.2ºC. An ECG reveals atrial fibrillation with a broad QRS. Which medication is the most likely cause of the overdose?

MRCP2-0811

A 67-year-old female visits her GP complaining of non-itchy rashes on her face, neck, and bilateral upper limbs that have been present for four days. She enjoys gardening and has a medical history of asthma and a previous myocardial infarction. During her last visit to the cardiology outpatient clinic, she was prescribed a new medication for arrhythmias. Which of the following drugs is the most probable cause of her symptoms?

MRCP2-0812

A 79-year-old man presents with pain after a fall. He slipped and injured himself on the pavement while returning from the local shops. He recalls feeling immediate pain in his right leg and was unable to stand up. A passerby called an ambulance and he was brought to the hospital. The patient has a medical history of ischaemic heart disease, mild dementia, hypertension, and high cholesterol.

Pelvic X-rays revealed an intertrochanteric right hip fracture. The patient is scheduled for surgery within the next five hours and has been instructed to fast. He has also been started on IV fluids. What is the appropriate management for his risk of venous thromboembolism (VTE)?

MRCP2-0813

A 58-year-old man arrives at the emergency department with central chest pain. He reports feeling a heavy pressure in the middle of his chest that extends to his left arm. He has used his GTN spray, but only two puffs as he is worried about getting a headache. The patient has a history of angina, a previous heart attack three years ago, and is currently a smoker with a 25 pack-year history.

The patient’s ECG shows ST depression in V3 to V5 of 2mm, pathological Q waves, and T wave inversion. His troponin level is elevated at 350 ng/L. He is given aspirin, clopidogrel, and morphine, which helps alleviate his pain. His GRACE score is high at 122, indicating a 7.9% chance of death within six months. After consulting with the cardiology registrar, he will undergo an angiogram within 12 hours. What is the next step in managing his acute coronary syndrome?

MRCP2-0814

A 16-year-old girl presented to the hospital with sudden pain in her left calf while playing soccer. She had no significant medical history and was not taking any medication. She denied smoking but mentioned that her aunt had a history of blood clotting problems.

During the examination, she complained of deep pain in her calf, but there was no pain on passive movement of the leg or ankle. A Doppler ultrasound scan of her leg veins did not show any evidence of venous thrombosis. However, her D-dimer level was 40 mg/L (<0.5). What would be the appropriate next step in her management?

MRCP2-0815

A 40 year old computer programmer presents to the Emergency Department with chest pains. He is stable with a blood pressure of 110/70 mmHg and a heart rate of 90 bpm, but has cool, dusky extremities and weak peripheral pulses. He reports central and left sided chest pain, sweating, and pallor, as well as a severe global headache. His chest is clear and heart sounds are normal, but an ECG shows pronounced inferior and lateral ST segment depression. A troponin test taken 4 hours after onset of chest pain is elevated. The patient’s wife reports that he has been taking clarithromycin for a chest infection and has been experiencing confusion, excitability, delusions, and visual hallucinations. He has also had stomach cramps and diarrhea for the past 2 days. The patient has a history of migraines and takes zolmitriptan and ergotamine prophylactically. What is the most likely explanation for this patient’s symptoms?

MRCP2-0816

A 25-year-old male presents to the ED after experiencing a seizure. His friends reported that he had jerking movements in all four limbs for 1-2 minutes and urinary incontinence. He is currently complaining of muscle aches and has vomited twice in the ED.

Upon examination, the patient appears confused and agitated, with myoclonic jerks present. His chest is clear, and his oxygen saturation is 98% on room air. His heart sounds are normal, but his pulse rate is 130 bpm, and his blood pressure is 161/84 mmHg. An ECG reveals sinus tachycardia, and his pupils measure 8mm and are equal and reactive. His temperature is 36.6ºC.

Blood tests reveal the following results:

– Hb: 138 g/l
– Platelets: 362 * 109/l
– WBC: 11.2 * 109/l
– Na+: 135 mmol/l
– K+: 2.7 mmol/l
– Urea: 12.6 mmol/l
– Creatinine: 187 µmol/l
– Bilirubin: 18 µmol/l
– ALP: 98 u/l
– ALT: 53 u/l
– γGT: 27 u/l
– Albumin: 32 g/l

What is the most likely cause of this patient’s presentation?