Archives: MRCP Part 2

MRCP2-0660

A 29-year-old woman is admitted to the surgical unit with an acute abdomen and a provisional diagnosis of appendicitis. During induction of anaesthesia, she had some stiffness of the jaw muscles. However, she later relaxed and surgery was commenced.

Within a few minutes, however, the stiffness of jaw had increased significantly and her limbs also became stiff. The surgical procedure had to be abandoned. Her body temperature rose to 42 °C. Her pulse was 120/min and thread, and blood pressure fell to 80/50 mmHg. Arterial blood gases revealed pCO2 of 8.0 kPa, pH 7.1 and HCO3– 28 mmol/l.

What is the most likely diagnosis?

MRCP2-0661

A 72-year-old man with urosepsis is admitted to the Elderly Care Ward and treated with IV fluids and gentamicin. On examination, his vital signs are stable, but he has suprapubic tenderness and a urinary catheter draining cloudy urine. Investigations reveal elevated WCC, neutrophils, and CRP, as well as a positive urine culture for Escherichia coli with sensitivities to gentamicin and ciprofloxacin. What is the next most appropriate step in managing this patient?

MRCP2-0662

A 39-year-old man in the early stages of Huntington’s disease is brought to the Emergency Department by ambulance after his wife found him unconscious with an empty bottle of codeine phosphate and a suicide note. He has been experiencing depression for a few weeks. On examination, his GCS score is 7, respiratory rate is 10/min, and BP is 100/60 mmHg. His blood gas analysis shows a pH of 7.25, pO2 of 6.8 kPa, and pCO2 of 7.5 kPa. What is the most appropriate management for this patient?

MRCP2-0663

A 35-year-old woman is brought to the emergency room by her husband. He found her unconscious and surrounded by empty bottles of aspirin. She had been feeling depressed for the past few weeks. On examination, her blood pressure is 120/80 mmHg, pulse is 90 bpm and regular. She is breathing normally with saturations of 98% on air. The abdomen is soft and non-tender. Investigations (blood tests) reveal the following:
Haemoglobin (Hb) 140 g/l (normal range: 120-160 g/l)
White cell count (WCC) 8.5 × 109/l (normal range: 4.0-11.0 × 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+) 4.2 mmol/l (normal range: 3.5-5.0 mmol/l)
Bicarbonate (HCO3-) 22 mmol/l (normal range: 22-28 mmol/l)
Creatinine (Cr) 80 μmol/l (normal range: 50-90 µmol/l)
pH 7.38 (normal range: 7.35-7.45)
What is the most appropriate next step in management?

MRCP2-0632

A 25-year-old woman presents to the emergency department after her flatmate found her drowsy in her bedroom. She had been incontinent of urine.

On examination the patient is obtunded with a Glasgow Coma Score of 7 (E1V2M4). The pupils are 7mm bilaterally and sluggishly reactive to light. The heart rate is 133 bpm and the blood pressure is 99/65 mmHg.

A 12-lead ECG reveals sinus tachycardia with a QT interval of 510 ms. The QRS duration is 115ms.

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

MRCP2-0633

A 38-year-old woman presents with dysuria, fever, and rigors that have developed over the past 24 hours. A urine sample is sent to the lab and cultures demonstrate sensitivity to gentamicin. Her renal function is normal and so she is started on a typical loading regimen.

After several days of being stable on a twice-daily regimen of gentamicin, blood tests are measured one day, pre-and post-evening dose:

Pre-dose 0.8mg/L (<1)
One hour post-dose 6 mg/L (3-5)

What is the most appropriate course of action?

MRCP2-0634

An 80-year-old man, who has been suffering from chronic obstructive pulmonary disease (COPD) for a few years, is brought to the Emergency Department after experiencing a grand mal seizure. His wife reports that he has been vomiting for a couple of days. The GP had prescribed him an antibiotic for a respiratory tract infection, along with a high-dose salmeterol fluticasone inhaler and oral theophylline. The investigations reveal abnormal results, including low potassium levels and high creatinine levels. Theophylline toxicity related to a drug interaction is suspected. What is the most likely cause of this toxicity?

MRCP2-0635

A 35-year-old man who has recently completed an opiate detoxification program is brought in by ambulance after collapsing at a local park. Next to him are an empty bottle of diazepam and an empty bottle of methadone.
Upon examination, his respiratory rate is 8/min, his BP is 90/70 mmHg, and his pulse is 85. His pupils are normal size and sluggishly reactive, and his Glasgow coma scale is 7/15.
The following are the results of his investigations:
pH 7.25 (7.36-7.44)
pO2 10.1 kPa (10.5-13.5)
pCO2 6.7 kPa (4.7-6.0)

What is the best course of therapy for him?

MRCP2-0636

A 65-year-old female patient was brought to the emergency department after collapsing at home. Upon arrival, the patient was unresponsive with no pulse and no recordable blood pressure. The paramedics had intubated her and established IV access. During transfer to the emergency department trolley, the patient was in VF and had received two DC shocks at appropriate energy levels. As the second cycle of chest compressions was completed, a third shock was delivered, but no pulse was palpable. What should be the immediate next step?

MRCP2-0637

A 49-year-old patient with a history of schizophrenia presents after being found on the floor of his sheltered accommodation home surrounded by many packets of medications. There is no collateral history. On examination, the patient is only verbally responsive to pain. There is evidence of vomitus around the oral cavity. You note that he is generally tremulous. Observations show heart rate 110/min, blood pressure 101/61 mmHg.

On the 12 lead ECG the P waves are present followed by QRS complexes. PR interval 0.12 seconds, QRS 0.12 seconds, corrected QT 0.48 seconds. What is the most likely causative agent?