Archives: MRCP Part 2

MRCP2-0771

A 36-year-old woman presents to the emergency department with agitation and sweating. She was recently started on fluoxetine for depression. She takes St John’s Wort over the counter. There is no history of substance abuse.

On examination, various muscle groups have sudden, brief involuntary twitching. She is diaphoretic, agitated and confused. There is hyperreflexia. She has a heart rate of 124 beats per minute and a temperature of 40ºC.

An ECG demonstrated sinus tachycardia.

What is the appropriate treatment for this likely diagnosis?

MRCP2-0772

You are asked to review a 45-year-old man in the emergency department. He is well known to the mental health liaison team because of his multiple suicide attempts. He is agitated and slightly confused and unable to give a precise history. He is able to tell you that he can’t see clearly and has a dry mouth.

His brother explains that the patient has been prescribed medicines for chronic neuropathic back pain and has taken them all after losing his job.

On examination he has symmetrically dilated pupils but no focal motor deficit. His heart sounds are normal and his lung fields are clear on auscultation. An ECG shows sinus tachycardia with a QRS of 170.

Bloods results are as follows:

Hb 130 g/l
Platelets 420 * 109/l
WBC 10.2 * 109/l
Na+ 137 mmol/l
K+ 4.1 mmol/l
Urea 4.9 mmol/l
Creatinine 90 µmol/l
Plasma Paracetamol <5 mmol/l You request an arterial blood gas which shows the following readings: pH 7.30
pCO2 3.5 kPa
pO2 14.0 kPa

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

MRCP2-0773

A 36-year-old woman is referred to oncology with a recent diagnosis of HER2 positive metastatic breast cancer. She has no significant medical history, is a non-smoker and non-drinker, and lives with her spouse and two young children. Trastuzumab is initiated for treatment. What medications should be avoided during concurrent administration?

MRCP2-0774

A 60-year-old man presents to the Emergency Department with a rash that has developed over the past 24 hours. He has been feeling increasingly unwell throughout the day. The patient has a medical history of hypertension and gout, and was recently started on allopurinol due to an increase in gout attacks. He also takes ramipril and amlodipine.

Upon examination, the patient has an erythematous maculopapular rash covering his entire body, with the worst of it on his trunk. He is tachycardic at 105 beats per minute, with a blood pressure of 110/55 mmHg and a temperature of 38.1 ºC. He reports residual pain in his right great toe, but no other focal signs or symptoms.

The patient’s blood tests reveal the following:

Hb 130 g/l Na+ 141 mmol/l
Platelets 550 * 109/l K+ 4.7 mmol/l
WBC 12.5 * 109/l Urea 6 mmol/l
Neuts 6 * 109/l Creatinine 95 µmol/l
Lymphs 5 * 109/l CRP 65 mg/l
Eosin 1.5 * 109/l

What is the most likely diagnosis?

MRCP2-0738

A 67-year-old man presents to the emergency department with dysuria and abdominal pain. He has a past medical history of chronic kidney disease stage IV. His medications include atorvastatin, amlodipine and ramipril.

On examination, there is mild suprapubic tenderness.

Urinalysis:

Nitrites positive
Leucocytes +++
Blood +
Protein +
Glucose negative

Blood tests:

Hb 137 g/L Male: (135-180)
Female: (115 – 160)
Platelets 189 * 109/L (150 – 400)
WBC 8.2 * 109/L (4.0 – 11.0)
Na+ 137 mmol/L (135 – 145)
K+ 4.2 mmol/L (3.5 – 5.0)
Urea 22.1 mmol/L (2.0 – 7.0)
Creatinine 278 µmol/L (55 – 120)
EGFR 23 mL/min/1.73m2 (90-120)
CRP 48 mg/L (< 5) Which antibiotic would be inappropriate for this likely diagnosis?

MRCP2-0739

A 50 year-old Russian woman presents with a 3 week history of joint pain in her wrists, shoulders, and knees on both sides. She also reports experiencing calf pain bilaterally. The patient has been initiated on first-line therapy for pulmonary tuberculosis 3 months ago. However, her symptoms resolved after taking aspirin.

What medication is the most probable cause of her symptoms?

MRCP2-0740

A 22-year-old college student presents to the Emergency Department with a history of progressive unsteadiness over the past few months. He has been struggling academically and has developed a habit of inhaling glue and aerosol deodorants. He had a previous episode of jaundice two years ago which resolved on its own, and one year ago he experienced sudden severe lower back pain that radiates to his right groin. He also reported intermittent blurring of vision, impaired judgement, irritability, and excitability.
On examination, he appears pale and euphoric, with a pulse of 90/min and a BP of 100/60 mmHg. Fundus examination reveals pale optic discs, horizontal nystagmus, and bilateral limb and gait ataxia. He has weak and atrophic distal muscles, absent ankle jerks, and flexor plantar reflexes.
Based on the likely diagnosis, what is the most concerning long-term renal complication?

MRCP2-0741

A 47-year-old woman with a history of Hashimoto’s thyroiditis presents to the clinic with recurrent symptoms of lethargy, constipation, cold intolerance, and pedal edema. These symptoms had previously resolved with levothyroxine treatment. She also has comorbidities of type 2 diabetes mellitus and hypertension, and was diagnosed with mycobacterium tuberculosis of the lung five months ago. Her current medications include levothyroxine, amlodipine, ramipril, metformin, gliclazide, rifampicin, isoniazid, and pyridoxine. On examination, her temperature is 36.5°C, pulse is 55 beats per minute, blood pressure is 165/102 mmHg, and respiratory rate is 15 breaths per minute. Thyroid function tests reveal a free thyroxine (T4) level of 5 pmol/L (10-25), a free triiodothyronine (T3) level of 3 pmol/L (5-10), and a thyroid-stimulating hormone level of 7.2 mU/L (0.4-5.0). What is the probable cause of her symptoms?

MRCP2-0742

A 54-year-old man with alcoholic cirrhosis is admitted to the hospital with confusion and decreased consciousness. His Glasgow Coma Scale (GCS) score is 13, blood pressure is 105/70 mmHg, and pulse is 85 bpm. He has abdominal distension with ascites and his abdomen is generally tender. Investigations reveal abnormal results for haemoglobin, white cell count, platelets, sodium, potassium, creatinine, C-reactive protein, alanine aminotransferase, and albumin. As a treatment plan, you decide to prescribe rifaximin. How does rifaximin work to alleviate symptoms of encephalopathy?

MRCP2-0743

A 38-year-old man with a history of HIV infection and asthma presents to the Emergency department with symptoms of fatigue, thirst, and lethargy that have been worsening over the past four weeks. He has also gained approximately 3 kilograms in weight during this time. The patient is currently taking darunavir and ritonavir for his HIV, and has recently been prescribed additional medications for his allergic rhinitis and poorly controlled asthma. Which medication is most likely responsible for the interaction with his antiretroviral medication and his current presentation?