Archives: MRCP Part 2

MRCP2-0696

A 22-year-old previously healthy male presents to the hospital with complaints of feeling generally unwell. He reports experiencing nausea, shortness of breath on minimal exertion, and occasional retrosternal chest pain. He has had two episodes of bile-stained vomiting in the past 24 hours but denies any diarrhea or abdominal pain. He also reports having a mild headache but denies any photophobia or neck stiffness.

Upon further questioning, the patient reveals that he recently returned from a safari vacation in Kenya. He had consulted his local travel clinic before traveling and was advised to take a combination of pyrimethamine 12.5mg and dapsone 100mg weekly as malaria prophylaxis due to a previous severe reaction to sulphonamides and intolerance to mefloquine.

During the physical examination, the patient appeared unwell and mildly cyanosed. He was afebrile with a pulse of 110 beats per minute and regular blood pressure of 90/60 mmHg. Although he was tachypnoeic with a respiratory rate of 20 breaths per minute, auscultation of his chest was normal. Abdominal and neurological examinations were entirely normal, but his oxygen saturation by pulse oximetry was 85%.

Shortly after the examination, the patient had a generalized tonic-clonic seizure that terminated spontaneously after 30 seconds. Although post-ictal, neurological examination revealed no localizing neurological deficit.

Further investigations revealed Heinz bodies and reticulocytosis on the blood film, and no malaria parasites were seen. The ECG showed a sinus tachycardia with ischemic changes in leads III, V5, and V6. The chest radiograph was normal, and a CT head scan with contrast was also normal.

Given the patient’s presentation and test results, what treatment should he receive?

MRCP2-0697

A 35-year-old homeless woman presents to the Emergency Department. Six hours previously, she had been seen in her usual state.
On admission, she has a Glasgow Coma Scale (GCS) score of 5, is afebrile, pulse 90 bpm, blood pressure 70/40 mmHg and RR 20/min. Her pupils are dilated and unreactive. Her fundi have blurred disc edges, and her breath smells sweet.
Investigations reveal the following:

Urinalysis ketones +
Glucose 2.5 mmol/l 3.5–5.5 mmol/l
Lactate 3.5 mmol/l 0.5–2.2 mmol/l
Plasma osmolar gap 30
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 3.0 mmol/l 3.5–5.0 mmol/l
Urea 8.0 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 200 μmol/l 50–120 µmol/l
Chloride (Cl-) 106 mmol/l 98–106 mmol/l
Bicarbonate (HCO32-) 15 mmol/l 24–30 mmol/l
Corrected calcium (Ca2+) 2.30 mmol/l 2.20–2.60 mmol/l
Prothrombin time (PT) 12.9 s 10.6–14.9 s
Salicylate Not detected
Arterial blood gas (ABG) pa(O2) 12.5 kPa, pa(CO2) 2.5 kPa
What is the most likely diagnosis?

MRCP2-0664

A 25-year-old man presents to the Emergency Department approximately 1 hour after ingesting 60 × 100 mg aspirin tablets. He has a history of depression and has attempted suicide in the past.

On examination, his blood pressure is 120/70 mmHg and pulse 80 bpm and regular. He weighs 70 kg and appears anxious.

Investigations:
Haemoglobin (Hb) 140 g/l (normal range: 130-170 g/l)
White cell count (WCC) 8.0 × 109/l (normal range: 4-11 × 109/l)
Platelets (PLT) 250 × 109/l (normal range: 150-400 × 109/l)
Sodium (Na+) 138 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+) 4.0 mmol/l (normal range: 3.5-5.0 mmol/l)
Bicarbonate 24 mmol/l (normal range: 22-30 mmol/l)
Creatinine 80 µmol/l (normal range: 50-120 µmol/l)
Glucose 6.0 mmol/l (normal range: 3.5-5.5 mmol/l)

What is the most appropriate next step in managing this patient?

MRCP2-0665

A 78-year-old woman is undergoing a percutaneous gastrostomy tube (PEG) after suffering a left hemiparesis due to an infarct stroke. She is agitated as the procedure begins, so she is premedicated with midazolam. As you achieve good views of the stomach the nurses alert you that her saturations have fallen to 85% and her respiration rate to 12. What is the most appropriate intervention in this situation?

MRCP2-0666

A 14-year-old boy is brought to the Emergency Department by ambulance. He has been found by his father, lying on the floor having taken an unknown overdose and a quantity of alcohol. His father is known to have diabetes, for which he takes medication.

On examination, he is unresponsive and hypotensive with a blood pressure of 80/60 mmHg; his pulse is 40 bpm. Finger prick glucose is 2.8 mmol/l. He has been given atropine 3 mg by the ambulance crew with little effect.

What is the most appropriate initial management in this case after assessing his airway?

MRCP2-0667

A 25-year-old woman is apprehended after a trip from Colombia and taken to the medical facility for evaluation as she becomes progressively restless. CT scan of the abdomen shows indications of swallowing multiple drug-filled packets, believed to be heroin. What is the preferred course of action in managing this situation?

MRCP2-0668

An 80-year-old man is admitted to the Acute Medical Unit following a fire at his property. He has a history of COPD, dementia, hypertension and type II diabetes. He smokes 20 cigarettes per day. He has evidence of smoke inhalation, with minimal oedema in the oropharynx and no evidence of airway obstruction. He reports to you that he has a headache and mild nausea.

Upon examination, he has a respiratory rate of 25 breaths per minute, with oxygen saturations of 92% on room air, a heart rate of 100 bpm, a temperature of 37.2 °C and blood pressure of 110/55 mmHg. His chest has bilaterally reduced air entry, and a chest X-ray reveals hyperexpanded lungs, with no evidence of consolidation. A routine electrocardiogram shows ST depression in the anterior leads.

What is the next course of action in managing this patient?

MRCP2-0669

A 55-year-old man with left ventricular failure presents with worsening renal function. He is currently euvolaemic and has been taking ramipril 5 mg once daily for the past two weeks. Prior to treatment, his renal function was within normal limits. However, his most recent test shows elevated levels of urea and creatinine, as well as hyperkalemia. What is the best course of action regarding his ACE inhibitor therapy?

MRCP2-0670

A 60-year-old woman with left ventricular failure has experienced a decline in renal function since starting lisinopril. She is currently on aspirin, furosemide, bisoprolol, and simvastatin, and is four days into a course of trimethoprim for a UTI. Prior to treatment, her renal function was within normal range, but her most recent test shows elevated levels of urea and creatinine. What is the best course of action regarding her ACE inhibitor therapy?

MRCP2-0671

A 23-year-old college student presents with a history of ingesting 50 tablets of digoxin which she took from her grandfathers medicine cabinet. On arrival, her heart rate is 80 bpm and regular, blood pressure 120/80 mmHg, no jugular venous distension, normal heart sounds and clear chest. She receives activated charcoal and her blood work shows the following results:

Potassium (K+) 4.2 mmol/l (normal range: 3.5–5.0 mmol/l)
Sodium (Na+) 138 mmol/l (normal range: 135–145 mmol/l)
Chloride (Cl-) 100 mmol/l (normal range: 98-106 mmol/l)
Bicarbonate (HCO3-) 24 mmol/l (normal range: 24–30 mmol/l)
Creatinine (Cr) 80 µmol/l (normal range: 50–120 µmol/l)
Digoxin 10.5 nmol/l

Electrocardiogram (ECG) shows sinus rhythm at 80 bpm.

After 2 hours, the patient complains of abdominal pain and her liver function tests show elevated levels of AST and ALT. What is the most appropriate further treatment for this patient?