Archives: MRCP Part 2

MRCP2-0761

A 35-year-old woman presents with a two-month history of weight loss and increasing agitation. On examination, she is noted to have a smooth goitre, a fine tremor of the outstretched hand, and a pulse of 98 beats per minute.

Investigations reveal:

– Free T4 42.6 pmol/L (10-22)
– Free T3 12.1 pmol/L (5-10)
– TSH <0.02 mU/L (0.4-5)
– Haemoglobin 128 g/L (115-165)
– White cell count 8.2 ×109/L (4-11)
– Neutrophil count 5.5 ×109/L (1.5-7)

She is commenced on carbimazole 40 mg daily and informed of the potential side effects of treatment. A further appointment was arranged for two months.

However, she re-presents three weeks later with a sore throat.

Investigations reveal:

– Free T4 29.9 pmol/L (10-22)
– Free T3 8.2 pmol/L (5-10)
– TSH <0.02 mU/L (0.4-5)
– Haemoglobin 130 g/L (115-165)
– White cell count 5.5 ×109/L (4-11)
– Neutrophil count 2.1 ×109/L (1.5-7)

What is the most appropriate next step in the management of this patient?

MRCP2-0762

A 70-year-old man comes to the clinic with feelings of sadness after losing his wife and has recently started taking St John’s wort. He has a history of chronic atrial fibrillation and diabetes. He is currently on digoxin, warfarin, and metformin. What are the potential risks for this patient?

MRCP2-0763

A 56-year-old man presents with a five-week history of malaise, reduced alertness, nausea, abdominal cramps, and arthralgia. He works as a painter and decorator and has been renovating old properties without always using his respirator. His physical examination is unremarkable except for mild abdominal tenderness. Laboratory investigations reveal basophilic stippling of erythrocytes, along with low hemoglobin and MCV levels, elevated ESR, and high plasma bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?

MRCP2-0764

A 42-year-old female patient diagnosed with stage IIIa breast cancer in her right breast visits the Oncology Clinic for evaluation. The tumour has been analyzed for receptor targeting of chemotherapy. To receive the benefits of trastuzumab, which receptor should be positive on the tumour’s histology?

MRCP2-0765

A 48-year-old man comes to the clinic complaining of sudden right ankle pain after hearing a popping sound. Upon examination, he is unable to plantar flex his right ankle. He reports no recent strenuous activity but mentions receiving treatment for a urinary tract infection. Which of the following antibiotics is most likely responsible for his current condition?

MRCP2-0766

A 28 year old well-nourished male electroplater presents with abdominal pain and neurological symptoms. He reports experiencing worsening symptoms over the past three months, including severe central abdominal pain, vomiting, diarrhoea, and a painful burning sensation in both feet. He also reports increasing clumsiness, loss of manual dexterity, and frequent tripping over his feet. Additionally, he describes a dimming of his vision over the past two weeks with a sepia tinge.

Upon examination, there is mild voluntary guarding of the abdomen but no discrete masses or organomegaly. The cardiorespiratory examination is normal. Neurological examination reveals distal weakness with MRC power grade 4/5 in all limbs but normal proximal power. There is a mild tremor present with his arms outstretched and trunk ataxia. Sensory examination discloses painful paraesthesia in the hands and feet with hyperalgesia. There is a loss of proprioception. The cranial nerves are notable in that a left sixth nerve palsy is present with accompanying diplopia. Visual acuity is reduced to 6/30 bilaterally and eye movements are painful. He has a bilateral ptosis. He is noted to have minimal body hair, including hairless arms and legs, lateral third of the eyebrow and temporal and crown baldness which he tells you occurred in the past month. He also has scaling of the palms and soles, tender glossitis and transverse white lines on all his nails. He is cyclothymic during assessment.

What is the most appropriate course of action for managing this patient?

MRCP2-0767

A 16-year-old male was hiking with friends in the local countryside when he was bitten on the left foot by a snake. One of his friends identified the snake as an adder (Vipera berus). An ambulance was called and the patient arrived at the hospital within 30 minutes.

Upon arrival, the patient was in pain and distressed. The ambulance crew had immobilized the bitten limb. The patient was conscious but appeared pale. His pulse was 115 beats per minute and regular, with blood pressure at 95/60 mmHg. He complained of abdominal pain and had vomited during the ambulance ride. Ten minutes after arriving in the Emergency department, he had profuse diarrhea. Two hours later, his blood pressure was 125/70 mmHg and pulse 105 beats per minute. Tissue swelling had extended proximally above the left ankle.

The following investigations were conducted:
– Haemoglobin: 148 g/L (130-180)
– White cell count: 16.5 ×109/L (4-11)
– Platelets: 390 ×109/L (150-400)
– Serum sodium: 142 mmol/L (137-144)
– Serum potassium: 3.8 mmol/L (3.5-4.9)
– Serum urea: 5.2 mmol/L (2.5-7.5)
– Serum creatinine: 90 µmol/L (60-110)
– Serum creatine kinase: 280 U/L (24-195)

Based on the information provided, which of the following symptoms or signs would indicate the need for antivenom administration?

MRCP2-0768

A 49-year-old woman is brought to the emergency department by ambulance after being found at home with a decreased level of consciousness. She has a medical history of open-angle glaucoma and takes regular acetazolamide. On examination, she is obtunded with a Glasgow coma scale of 10/15. IV fluids are administered and arterial blood gas and blood tests are obtained. Based on the results, what is the most likely diagnosis?

Arterial blood gas results:

pH 7.24 (7.35-7.45)
paO2 10.2 kPa (10-14)
paCO2 5.5 kPa (4.5 – 6.0
Base excess -4.2 mmol/L (-2 – +2)
Chloride 95 mmol/L (95-105)
Bicarbonate 14 mmol/L (22-26)
Glucose 5.0 mmol/L (4-11)
Lactate 2.2 mmol/L (0.5-2.0)
SaO2 95 % (94-98)

Blood test results:

Hb 137 g/L Male: (135-180)
Female: (115 – 160)
Platelets 189 * 109/L (150 – 400)
WBC 4.4 * 109/L (4.0 – 11.0)
Na+ 140 mmol/L (135 – 145)
K+ 5.0 mmol/L (3.5 – 5.0)
Urea 8.0 mmol/L (2.0 – 7.0)
Creatinine 111 µmol/L (55 – 120)
CRP 8 mg/L (< 5)
Measured osmolality 320 mOsm/Kg (280-290)

MRCP2-0769

A 73-year-old male presents with progressive ascending motor weakness, palpitation, and back pain for the past 72 hours. The patient is diagnosed with Guillain-Barre syndrome and started on IVIg treatment with close monitoring on the neurology ward. On the fourth day of treatment, you review the patient’s bloods and notice a change in sodium levels: Na 145 → 141 → 134 → 130 → 126. Despite feeling better after the drip, the patient denies any respiratory or gastrointestinal symptoms. Upon examination, the patient appears comfortable in bed, with a JVP 2/3 cm above the angle of Louis, warm peripheries, and a capillary refill time of 2 seconds. The chest is clear on auscultation, cardiovascular examination is unremarkable, and neurological examination remains unchanged from admission. What is your plan for managing this patient?

MRCP2-0770

A 49-year-old man presents to the Medical Admissions unit with complaints of palpitations. He has a medical history of hereditary obstructive cardiomyopathy (HOCM) and has been taking amiodarone for the past year. He denies any personal or family history of autoimmune disease.

Upon examination, the patient appears flushed and diaphoretic. He is thin and has a fine tremor when his hands are outstretched. No goitre is detected.

The patient’s vital signs are as follows: heart rate 102/min; blood pressure 126/82 mmHg; respiratory rate 14/min; temperature 37.9ºC; oxygen saturations 97% on air.

The following blood test results are obtained:

Free T4 28.6 pmol/L (12 – 22)
Free T3 9.1 pmol/L (3.1 – 6.8)
TSH < 0.05 mU/L (0.27 - 4.2) Based on the likely diagnosis, what is the most appropriate course of management?