Archives: MRCP Part 2

MRCP2-0793

Lena is a 23-year-old woman who has been brought to the emergency department by her roommate after being found collapsed on the floor surrounded by unmarked bottles. Lena has a history of depression and had been arguing with her boyfriend earlier in the day. Her friend was concerned for her safety and brought her to the hospital. Lena is unsure of what was in the bottles she was found with.

Upon arrival at the emergency department, Lena was disoriented and unable to recall why she was there. She began experiencing nausea and vomiting, and after an hour, she became extremely drowsy and unresponsive.

Physical examination did not reveal any significant findings, and her skin color was normal. There was no tenderness in her abdomen, but her respiratory rate was elevated at 30 breaths per minute.

Blood tests showed a hemoglobin level of 140 g/L, platelet count of 250 * 109/L, and a white blood cell count of 7.0 * 109/L. Her electrolyte levels were within normal limits, but her bicarbonate level was low at 12 mmol/L. Her measured osmolarity was elevated at 350 mOsm/kg. Liver function tests were normal.

Arterial blood gases showed a pH of 7.27, pO2 of 13.7 kPa, pCO2 of 3.2 kPa, and an HCO3 level of 12.

An ECG showed sinus tachycardia with no abnormalities in the QRS complex.

What substance is likely responsible for Lena’s symptoms?

MRCP2-0794

A 20-year-old male is discovered collapsed in a dimly lit alleyway. He has no known place of residence. Despite being very drowsy, he is aware of his surroundings and has a Glasgow coma scale score of 14/15 (E3, V5, M6). Although he denies drinking any alcohol, he smells of it. His visual acuity is impaired in both eyes, and he has a tremor in his outstretched hands, but the rest of his examination is unremarkable. His blood pressure is 145/76 mmHg, his pulse is regular at 101/min, his respiratory rate is 22/min, and his oxygen saturation is 95% on room air.

Investigations:

Hb 11.3 g/dl
MCV 102 fl
Platelets 110 * 109/l
WBC 12 * 109/l
Creatinine 117 umol/L
Urea 9 umol/L
Na+ 146 mmol/L
K+ 5.4 mmol/L
CL- 109 mmol/L

Arterial blood gas:

pH 7.21
PaO2 10.9 kPa
PaCO2 4.2 kPa
HCO3 16 mEq/L

What is the next best course of action in managing this patient, given the suspected toxin ingestion?

MRCP2-0795

A 25-year-old woman, the daughter of a rancher, presents with a history of gradual weight loss, loss of appetite, vomiting, and difficulty passing stools for the past six months. She had recently been actively involved in helping her father to control the rodent population in their barns.
She also experienced frequent headaches and occasional episodes of disorientation, but these resolved spontaneously.
For the past two months, she had noticed a tingling sensation in her toes.
On examination, she had thickened palms and some horizontal ridges on her nails.
She was alert and cooperative. Mild weakness and atrophy were observed in the small muscles of her feet. Tendon reflexes were absent, and plantar responses were flexor. There was reduced sensitivity to pinprick in the distal fingertips and feet.
What is the most probable diagnosis?

MRCP2-0796

A 35-year-old female presents to the Emergency Department with complaints of abdominal bloating and weight gain. She reports not having a menstrual period for approximately 5 months. Recently, she was diagnosed with partial onset seizures and is taking carbamazepine. She also takes the combined oral contraceptive pill. Her blood pressure is 120/80 mmHg, and her pulse is regular at 70 bpm. On examination, her BMI is 29 kg/m2, and she has noticeable acne. MRI of the brain was unremarkable. Laboratory results show a hemoglobin level of 110 g/l (normal range: 115-155 g/l), a white cell count of 6.5 × 109/l (normal range: 4.0-11.0 × 109/l), a platelet count of 280 × 109/l (normal range: 150-400 × 109/l), a sodium level of 142 mmol/l (normal range: 135-145 mmol/l), and a potassium level of 4.2 mmol/l (normal range: 3.5-5.0 mmol/l). What is the most likely cause of her weight gain?

MRCP2-0797

A 54-year-old male presents to the emergency department confused and unsteady while walking. What is the probable cause of his presentation? He has a history of alcohol excess and bipolar disorder, for which he takes lithium. His wife found him confused about two hours before presenting to the hospital. The patient had been well that morning, but his recent job loss triggered a low mood. On examination, he had a flushed complexion, slurred speech, horizontal nystagmus, and a marked ataxic gait. Blood results showed an elevated anion gap, low bicarbonate, and high osmolar gap. Ethanol was detected in his blood, and lithium levels were pending.

MRCP2-0798

A 29-year-old woman was brought to the Emergency Department in a drowsy and unwell state after a suspected suicide attempt at home. The patient had a history of schizoaffective disorder and was receiving treatment under community psychiatry. No other past medical history was known. The paramedics who brought the patient also brought the medications found at her home, which included quetiapine, levomepromazine, zopiclone, and oxazepam. They did not find any empty medication packets or blister packs at the patient’s home.

On initial assessment, the patient’s consciousness level was reduced, but other observations were unremarkable. The following were the basic observations at presentation:

Blood pressure: 150/79 mmHg
Heart rate: 89 bpm
Respiratory rate: 20 / min
O2 saturations (15 L O2):100 %
Glasgow coma score: M5 V3 E2
Blood glucose: 7.0 mmol / L
Temperature: 36.8ºC

An arterial blood sample (15 L O2) was taken, and the results were as follows:

pH 7.19
PaCO2 3.3 kPa
PaO2 21.2 kPa
Bicarbonate 8.9 mmol / L (reference 20.0-26.0)

Sodium 142 mmol / L
Potassium 3.6 mmol / L
Calcium 2.13 mmol / L (reference 2.20-2.60)
Chloride 110 mmol / L (reference 99-108)
Urea 5.2 mmol / L
Creatinine 110 micromol / L
Lactate 26 mmol / L
Plasma osmolality 380 mmol / Kg (reference 280-295)
Haemoglobin 12.0 g / dL

What is the most likely cause of the patient’s reduced consciousness level based on the above blood results?

MRCP2-0799

A 32-year-old man has been referred to an endocrinology clinic to assess the adverse effects of his anabolic steroid use. He has been a regular user for the past 6 years to support his body-building training but has recently decided to stop due to concerns about the potential health risks. He reports using an intramuscular injection of long-acting synthetic testosterone derivative every two weeks and taking a 4-week break every 12 weeks to limit side-effects. He denies using oral or topical synthetic testosterone preparations and always uses sterile injecting equipment.

The patient reports significant gynaecomastia and male pattern baldness since starting steroid use, as well as a ruptured right biceps tendon 2 years ago that required surgical repair and rehabilitation. He denies symptoms of cardiac or liver disease, takes no regular medications, and reports an alcohol consumption of 15-20 units per week. On examination, he appears highly muscular and lean with moderate gynaecomastia but no signs of chronic liver disease. Cardiovascular and respiratory systems are unremarkable.

Blood test results show elevated HbA1C, total cholesterol, and fasting LDL cholesterol, as well as decreased fasting HDL cholesterol and elevated prolactin. Results for luteinising hormone, follicle-stimulating hormone, testosterone, and epitestosterone are pending. Which pattern of pending blood test results is consistent with the patient’s anabolic steroid use?

MRCP2-0800

A 55-year-old man is brought into the emergency department by the police. He appears drowsy and confused, with an unkempt appearance. Unfortunately, he is unable to provide a coherent history due to his confusion. Upon examination, his pulse rate is 60 beats per minute, blood pressure is 90/60 mmHg, respiratory rate is 23 per minute, and his temperature is 35.2°C. There are no remarkable findings upon examination of his heart, lungs, and abdomen. There is no evidence of a focal neurological deficit, but his eyes open to pain, pupils are dilated with absent light responses, and his speech is slurred and incoherent. His serum alcohol level is 0.78 g/L. An arterial blood gas test reveals a pH of 7.30, pO2 of 10.1 kPa, pCO2 of 2.9 kPa, sodium of 142 mmol/L, chloride of 100 mmol/L, potassium of 4.2 mmol/L, bicarbonate of 12.9 mmol/L, urea of 9.2 mmol/L, and creatinine of 103 μmol/L. His glucose level is 8.4 mmol/L. A urine dipstick test is positive for 1+ ketones and 1+ leukocytes, but negative for nitrites. What is the most likely diagnosis?

MRCP2-0775

A 50-year-old woman presents with fever, night sweats, and weight loss. She has a medical history of type 1 diabetes and was recently found to have microaneurysms and dot and blot haemorrhages on retinal screening. Despite no previous visual problems, she is admitted to the hospital and diagnosed with HIV with a CD4 count of 140 cells/µL. After starting treatment with Rifampicin, Isoniazid, Pyrazinamide, ethambutol, pyridoxine, cotrimoxazole, and antiretroviral therapy with Efavirenz, emtricitabine, and tenofovir, she is discharged and makes a good recovery. However, a few months later, she reports increasingly blurry vision, and fundoscopy reveals pale optic discs, microaneurysms, and blot haemorrhages. What is the most likely cause of her visual symptoms?

MRCP2-0776

A 49-year-old woman with a history of obesity presents with left leg cellulitis. Upon admission, blood cultures are taken and she is started on IV flucloxacillin. However, she suddenly complains of feeling itchy and light-headed. Upon examination, her respiratory rate is 30 breaths per minute, oxygen saturations are at 90% on air, heart rate is 127 beats per minute, blood pressure is 75/42 mmHg, and temperature is 36.8°C. Chest examination reveals widespread wheeze, but the cellulitis has not spread beyond the markings. What can be said about the suspected diagnosis?