Archives: MRCP Part 2

MRCP2-0698

A 49-year-old Lithuanian man is brought to the Emergency Department by two of his friends. He is confused and aggressive and walks with an unsteady gait. History is difficult to obtain from the patient due to slurring of his speech and a slight language barrier. You note that he fails to meet your gaze when you are talking to him.

Examination shows a GCS of 15/15 but he is drowsy and irritable. There is a vague smell of alcohol on his breath. He is flushed in the face and his eyes are red and hyperaemic. Pupils are slow to react to direct light but equal in size. The cardiorespiratory examination is unremarkable aside from a respiratory rate of only 8/min but SpO2 is 98% on air. The abdomen is soft and non-tender with no hepatomegaly and no signs of chronic liver disease. Despite the department being well lit, he asks you to turn the lights on.

Biochemistry reveals:

Haemoglobin 149 g/L Sodium 150 mmol/L pH 7.25
White cells 8.9×109/L Potassium 5.9mmol/L pC02 3.9kPa
Neutrophils 5.9×109/L Urea 13.8 mmol/L pO2 12.6kPa (air)
Platelets 229×109/L Creatinine 156 mol/L HCO3- 12.5 mmol/L
Prothrombin time 11 sec Glucose 24.7mmol/L BE -13.2mEq/L
Ethanol 110 mg/dL Chloride 100 mmol/L Lactate 2.0mmol/L
Anion gap 38 Osmolar gap 25 (-10 to +15)

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

MRCP2-0699

A middle-aged homeless man in his early 50s presents to the emergency department with a six-hour history of profuse vomiting, nausea, and headache. He appears confused and disheveled, with a ketone odor on his breath. Twelve hours after admission, his condition worsens with complaints of blurred vision, fixed and dilated pupils, and a sharp increase in respiratory rate leading to unconsciousness. Laboratory investigations reveal abnormal values for plasma bicarbonate, lactate, and chloride, among others, and crystals are seen in his urine. What is the definitive treatment required for managing this patient?

MRCP2-0700

A middle-aged homeless man in his early 50s is brought to the emergency department with a six hour history of profuse vomiting. He complains of nausea and headache.

The history available is sketchy. He is of no fixed abode and denies having any previous medical problems. He appears unkempt and is confused – oriented to person but not time or place. He is afebrile. His breath smells of ketones.

Twelve hours after admission his condition deteriorates. He complains of blurred vision and his pupils are fixed and dilated; his respiratory rate increases sharply over the next few minutes and he becomes unconscious.

Investigations show:

Hb 138 g/L (130-180)
WCC 7.1 ×109/L (4-11)
Platelets 401 ×109/L (150-400)
Plasma sodium 135 mmol/L (137-144)
Plasma potassium 5.0 mmol/L (3.5-4.9)
Plasma urea 5.8 mmol/L (2.5-7.5)
Plasma creatinine 110 µmol/L (60-110)
Plasma chloride 100 mmol/L (95-107)
Plasma bicarbonate 12 mmol/L (20-28)
Plasma glucose 5.5 mmol/L (3.0-6.0)
Plasma lactate 4.1 mmol/L (0.6-1.7)
PaO2 12 kPa (11.3-12.6)
PaCO2 4.2 kPa (4.7-6.0)
pH 7.22 (7.36-7.44)
Urine microscopy Crystals seen

What is the calculated anion gap in this case?

MRCP2-0679

A 35-year-old woman presents to the Emergency Department with a 1-day history of confusion and restlessness. She has become progressively more unwell throughout the day and has started vomiting within the last two hours. Her medical history includes type I diabetes and depression.

On examination, she has a temperature of 38.5 °C. She is tachycardic with a heart rate of 133 bpm and her blood pressure is 170/110 mmHg. Her face is red and flushed. Her examination is difficult due to increased agitation, but there is an obvious tremor and hyperreflexia of her upper and lower limbs.

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

MRCP2-0680

You are urgently requested to assess a 28-year-old zookeeper who has been bitten by a coral snake and is experiencing acute symptoms. He is currently hypotensive with a blood pressure reading of 85/60 mmHg, has a regular pulse of 95 bpm, and is losing consciousness with evident muscle weakness and difficulty swallowing his saliva.

What is the most accurate statement regarding the immediate treatment of this snake bite?

MRCP2-0681

A 47-year-old woman with stable bipolar affective disorder, treated with lithium carbonate, is seen for the second time in the General Medical Outpatients Clinic. She was originally referred by the Psychiatric team with polyuria associated with excessive thirst and drinking.
The psychiatric nurse who has been seeing her in the community wondered whether she might be suffering from diabetes mellitus; however, a capillary blood glucose measurement was normal.
Her results from the last visit are as follows:
Investigation Result Normal Values
Fasting blood glucose 6.9 mmol/l 3.9 – 7.1 mmol/l
Potassium (K+) 3.9 mmol/l 3.5 – 5.0 mmol/l
Serum osmolality 309 mOsmol/kg 275 – 295 mOsmol/kg
What is the most effective course of action?

MRCP2-0682

A 24-year-old woman with a history of chronic asthma presents to her General Practitioner with complaints of nausea and vomiting for the past two days. She reports having an argument with her mother over something trivial while watching her regular television show just before the onset of her symptoms. She vomited several times after supper that night and went to bed early. Since then, she has been feeling unwell with a headache and abdominal pain. On examination, she appears drowsy but oriented, and a coarse tremor is evident. Pupils are normal and reactive. Her chest is clear, and she has normal heart sounds. There is epigastric discomfort on palpation of her abdomen. Observations reveal a heart rate of 130 bpm, respiratory rate of 26 breaths per minute, and blood pressure of 100/66 mmHg. Laboratory investigations show a decreased potassium level of 2.5 mmol/l and an electrocardiogram (ECG) reveals sinus tachycardia with a rate of 134 bpm. What is the next step in management for this patient?

MRCP2-0683

A 65-year-old woman is receiving chemotherapy with a paclitaxel- and trastuzumab-based regimen and is being monitored after each cycle for changes in her ejection fraction. Following the third cycle, she experiences increased shortness of breath and decreased exercise tolerance. Her ejection fraction has decreased from 56% at baseline to 42%. On chest auscultation, there are bi-basal crackles, but no ankle swelling is present. Her blood pressure is 110/85 mmHg. What is the most appropriate next step?

MRCP2-0684

A 36-year-old man is brought to the Emergency Department by ambulance after being found unconscious by his roommate. On examination, he has a Glasgow Coma Scale (GCS) score of 6, blood pressure (BP) 80/50 mmHg and a ventricular tachycardia (VT) with a rate of 180 bpm. There are several empty bottles of amitriptyline 50 mg tablets found in his room.
Investigations:

pH 7.20 7.35–7.45
pa(CO2) 6.1 kPa 4.6–6.0 kPa
pa(O2) 7.2 kPa 10.5–13.5 kPa
He is intubated and ventilated and admitted to the Intensive Care Unit (ICU).
What is the most appropriate additional intervention in managing this tricyclic overdose?

MRCP2-0685

A 24-year-old woman is brought to the Emergency Department after taking an overdose of her grandfather’s warfarin. She has been experiencing low mood for the past four months and has had suicidal thoughts. She admits to taking between 12 and 15 tablets eight hours ago. There is no history of bleeding or bruising in the last eight hours. Her medical history includes depression and mild asthma, for which she takes Clenil Modulite® and salbutamol as required. On examination, she appears upset, but her vital signs are normal, and there are no signs of bruising or petechiae. Her laboratory results show an elevated INR of 1.5.

What is the next step in the immediate management of this patient?