Archives: MRCP Part 2

MRCP2-0650

A 35-year-old woman with rheumatoid arthritis has been diagnosed in the community with a prolonged urinary tract infection. For her rheumatoid arthritis she has been stable on methotrexate for nearly a year and besides ibuprofen she takes no other regular medications.

The doctor has requested a follow-up blood test which is shown below.

Baseline bloods were taken 2 months ago:

Hb 118 g/l
Platelets 320 * 109/l
WBC 4.2 * 109/l

Yesterday the bloods showed the following:

Hb 99 g/l
Platelets 290 * 109/l
WBC 1.8 * 109/l

Which of the following drugs is most likely responsible?

MRCP2-0651

A 35-year-old man presents to the emergency department with chest pain. He reports feeling a squeezing sensation in the center of his chest and mild breathlessness. He works as a stockbroker and admits to occasional smoking and binge-drinking on weekends.
On examination, he appears tremulous and sweaty with a temperature of 37.9ºC. His heart rate is 140 bpm, blood pressure is 143/87 mmHg, and he has increased rigidity in his limbs. His pupils are dilated and reactive to light. Investigations reveal an NSTEMI with ST depression in I, aVL, V5, and V6 on ECG. Dual antiplatelet therapy, fondaparinux, and sublingual GTN are initiated for ACS.
What is the most appropriate medication to add to the ACS protocol?

MRCP2-0652

A 26-year-old male presents to the acute medical unit with confusion. His mother reports that he has been acting strangely for the past 24 hours. He has a medical history of epilepsy, asthma, and depression, and takes salbutamol, sertraline, and sodium valproate. On examination, myoclonus is noted and his Glasgow coma score is reduced to 13 (M6, V4, E3).

The following blood results are obtained:

Hb 132 g/l Na+ 142 mmol/l Bilirubin 18 µmol/l
Platelets 328 * 109/l K+ 4.1 mmol/l ALP 72 u/l
WBC 8.7 * 109/l Urea 6.8 mmol/l ALT 184 u/l
Neuts 7.4 * 109/l Creatinine 72 µmol/l INR 1.1
Lymphs 1.2 * 109/l Albumin 42 g/l Plasma ammonia 72 μmol/L (normal range 11–32 μmol/L)

What is the most likely cause of this patient’s presentation?

MRCP2-0653

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 some old properties without always using his respirator. His physical examination is unremarkable except for mild abdominal tenderness. Blood tests show low hemoglobin, small red blood cells, and basophilic stippling of erythrocytes. Which of the following treatments is unsuitable for this patient’s condition?

MRCP2-0654

You receive a request for a second opinion from a GP who has performed a general physical check on one of their new patients. He is a 52-year-old man who is from Thailand. He had been complaining of low mood, fatigue and sensitivity to the cold. His body mass index is 31 kg/m². The following is a list of investigations performed by the GP.

Na+ 141 mmol/l
K+ 4.8 mmol/l
Urea 9.8 mmol/l
Creatinine 142 µmol/l
CRP 4 mg/l

Bilirubin 14 µmol/l
ALP 86 u/l
ALT 27 u/l
Calcium 2.89 mmol/l
Albumin 39 g/l
TSH 24.0 mU/l
Free T4 0.8 pmol/l
Free T3 0.4 pmol/l

ECG: Heart rate 68, sinus rhythm, QRS width 128ms, flattened T waves V1 to V6

The patient has told the GP that he takes one medication regularly but is unable to give the name. Which medication is most likely to cause the following abnormalities?

MRCP2-0655

A 55 year-old man presents to the medical assessment unit with a two day history of nausea and vomiting. His medical history is currently unavailable, and he is unable to recall his past medical problems. He is currently an inpatient at the local psychiatry facility.

Upon examination, he appears drowsy with an ataxic gait. Neurological examination reveals normal tone with generalised reduced power. He also has a coarse tremor when his hands are outstretched. Cardiorespiratory examination is unremarkable.

Based on his ECG showing sinus arrhythmia at 90 beats per minute and T wave inversion in leads V1-V3, along with his observations of a blood pressure of 150/90 mmHg, heart rate of 90 beats per minute, respiratory rate of 16 breaths per minute, oxygen saturations of 99% on room air, and temperature of 37.3ºC, what is the most likely cause of his symptoms?

MRCP2-0656

A 43-year-old woman with a medical history of bipolar affective disorder is hospitalized due to tremors, nausea, and diarrhea. During the examination, it is observed that she has bilateral past-pointing and intention tremors. Her serum lithium level is 2.3 mmol/L. The patient’s primary care physician has recently prescribed a new medication for her hypertension. Which of the following medications is the most probable cause of the lithium toxicity?

MRCP2-0657

A 57-year-old man with a medical history of ischaemic heart disease, hypertension, and manic depressive illness presented for a routine outpatient review. The patient reported feeling more lightheaded than usual, accompanied by nausea, and experiencing tremors and jitteriness. Six weeks prior, his GP noted elevated blood pressure at 162/85 mmHg and prescribed bendroflumethiazide 2.5 mg once daily in addition to his regular medications of atenolol 50 mg once daily, aspirin 75 mg once daily, and lithium carbonate modified release 400 mg once daily. Two weeks ago, the patient was diagnosed with acute gout and started on indomethacin 50 mg tds. During the outpatient review, the patient exhibited a fine resting tremor and brisk reflexes throughout, with a blood pressure of 90/67 mmHg and a resting bradycardia of 50 beats per minute. An electrocardiogram revealed first-degree heart block with an occasional junctional escape rhythm. An urgent lithium level was reported as 4.0 mmol/L (therapeutic range 0.5-1.5 mmol/L). What is the appropriate treatment for this patient?

MRCP2-0658

You are asked to assess a 49-year-old female patient who was admitted to the Surgical Ward five hours ago after undergoing an elective open right hemicolectomy for adenocarcinoma of the caecum. The surgery was uneventful, and the patient is receiving a local anaesthetic infusion to rectus sheath catheters and an oxycodone PCA for postoperative pain management. She has no significant medical history and no known drug allergies.

Half an hour ago, the nursing team administered postoperative antibiotics and replacement intravenous fluids to the patient, whose vital signs were all within normal limits. However, the patient has recently reported experiencing tinnitus, and she has just had a self-limiting seizure and is currently post-ictal with a Glasgow Coma Scale (GCS) score of 10. Her vital signs are as follows:
– Heart rate: 45 bpm
– Blood pressure: 78/35 mmHg
– Respiratory rate: 25/min
– Temperature: 36.5ºC
– Blood glucose: 4.4mmol/l

What immediate treatment should be initiated?

MRCP2-0659

A seventy-five-year-old woman is evaluated for asymptomatic cervical lymphadenopathy. She has a complicated medical history of hypertension, type II diabetes, chronic kidney disease, osteoporosis, Paget’s disease, and epilepsy. Her current medications include ramipril, atorvastatin, sodium bicarbonate, linagliptin, zoledronic acid, and phenytoin. Which medication could be responsible for her lymphadenopathy?