Archives: MRCP Part 2

MRCP2-0638

As a registrar on the palliative care ward, you encounter a 59-year-old woman who has been admitted for symptom control. She has a medical history of metastatic pancreatic cancer and diabetic nephropathy. Despite titration of morphine, gabapentin, and duloxetine, she has been experiencing severe abdominal pain.

Her blood results are as follows:

– Hb: 75 g/l
– Platelets: 224 * 109/l
– WBC: 14.9 * 109/l
– Neuts: 12.9 * 109/l
– Na+: 138 mmol/l
– K+: 3.8 mmol/l
– Urea: 18.6 mmol/l
– Creatinine: 288 µmol/l
– eGFR: 22 mL/min

To alleviate her pain, you decide to prescribe an opioid that acts as a neuropathic agent through NMDA antagonism. What is the most appropriate analgesic for her?

MRCP2-0639

A 20-year-old woman presents to the emergency department after taking an overdose of paracetamol following an argument with her mother. She regrets her actions and is requesting treatment.

The patient ingested approximately 28 tablets of 500 mg paracetamol 40 minutes prior to arrival at the hospital. She has no history of mental or physical health issues and has never taken an overdose before. She does not consume alcohol and is not on any regular medications. On examination, she appears anxious but alert, with normal physiological parameters and no abnormal physical signs.

Lab results show a haemoglobin level of 128 g/dL, mean cell volume of 95.0 fl, white cell count of 8.4 x 10>3/microlitre, platelets of 198 x 10>3/microlitre, urea of 4.3 mmol/L, creatinine of 67 micromol/L, sodium of 137 mmol/L, potassium of 4.3 mmol/L, albumin of 45 g/L (reference 35-50), alkaline phosphatase of 56 U/L (reference 35-100), ALT of 34 U/L (reference 3-36), bilirubin of 15 micromol/L (reference < 26), and an international normalized ratio of 1.1 (reference 0.8-1.2). What is the best course of action for managing her paracetamol overdose?

MRCP2-0640

A 40-year-old farmer who is struggling financially arrives at the Emergency department 30 minutes after ingesting an unknown amount of paraquat-based weed killer. He has a Glasgow coma scale score of 15 and expresses remorse for his actions. He reports feeling nauseous and experiencing a burning sensation in his mouth. Upon examination, his blood pressure is 135/80 mmHg, his pulse is regular at 85 beats per minute, and there are no abnormal physical findings. What is the primary intervention that should be taken?

MRCP2-0641

A 45-year-old office worker has been referred to the medical team after experiencing sudden lip swelling. She has a history of high blood pressure and her doctor recently changed her medication for this condition. Upon examination, she has swelling in her lips and tongue, but thankfully her airways are not affected. What medication is the most likely cause of this reaction?

MRCP2-0642

A 32-year-old hiker comes to the Emergency Department, reporting a snake bite while on a trail. She believes it was a adder and asks if she needs antivenom.

Upon examination, her BP is 130/70 mmHg, her pulse is 90 bpm and regular, and she appears nervous. You observe the bite marks on her right ankle with some redness and swelling around the area.

What is a potential indication for administering antivenom in this case?

MRCP2-0643

A 25-year-old man presents to the Emergency Department after intentionally ingesting an unknown number of pills following a fight with his partner, 3 hours ago. He expresses remorse and denies any desire to die. He is uncertain about the type of pills he took but thinks they might have been painkillers.
Upon examination, he has a Glasgow Coma Score of 15, BP of 128/82 mmHg, pulse of 82 and regular, and appears anxious but otherwise asymptomatic.
What is the most appropriate next step in the management of this patient?

MRCP2-0644

A 25-year-old man is brought to the hospital after ingesting 20 × 300 mg aspirin tablets. He complains of severe headache, dizziness, and nausea about 2 hours after the overdose. Upon examination, his BP is 140/80 mmHg, his pulse is 90/min regular, and he appears restless. His respiratory rate is 28/min.
Which of the following arterial blood gas results would be most consistent with his symptoms?

MRCP2-0645

A 25-year-old man presents to the Emergency Department with vomiting and inability to tolerate any food. He confesses to taking an overdose of 60 × 500 mg paracetamol tablets two days ago due to personal issues. On examination, he is tender in the right upper quadrant of his abdomen and his blood pressure is 95/60 mmHg with a pulse of 90/min. The following investigations were obtained:

Haemoglobin (Hb) 130 g/l (135 – 175 g/l)
White cell count (WCC) 12.5 × 109/l (4.0 – 11.0 × 109/l)
Platelet (PLT) 180 × 109/l (150 – 400 × 109/l)
Sodium (Na+) 138 mmol/l (135 – 145 mmol/l)
Potassium (K+) 5.5 mmol/l (3.5 – 5.0 mmol/l)
Bicarbonate (HCO3-) 20 mmol/l (22 – 29 mmol/l)
Creatinine (Cr) 150 µmol/l (50 – 120 µmol/l)
International normalised ratio (INR) 3.8 (< 1.1)
Alanine transaminase (ALT) 4200 u/l (7 – 55 u/l)

Which of the above findings is the most crucial factor in determining the need for referral to a specialist unit?

MRCP2-0646

A 26-year-old man with a history of depression and self-harm presents to the emergency department after an impulsive overdose of ferrous sulphate. He weighs 70kg and has ingested 70 x 200mg ferrous sulphate tablets, equivalent to 5600 mg of elemental iron (80 mg/kg). He denies any abdominal pain, diarrhoea or vomiting. On examination, his vital signs are stable and blood tests show elevated serum iron levels. What is the appropriate initial medical management for this patient?

MRCP2-0614

A 28-year-old mechanic is brought to the emergency department by his girlfriend. He is confused and lethargic. According to his girlfriend, they had been drinking alcohol the previous night, and he has been increasingly confused throughout the day despite no further alcohol intake. She also reports that he has been feeling low and has expressed suicidal thoughts recently.

Upon assessment, his Glasgow coma scale is 14/15, and his pupils are equal and reactive to light. His blood pressure is 124/81 mmHg, and his heart rate is 97/minute. He has a respiratory rate of 32/minute and oxygen saturations of 94% on room air. There is bilateral flank tenderness, but the rest of the clinical exam is unremarkable.

His urine toxicology screen is negative, but the urine dipstick is positive for blood. The arterial blood gas shows a pH of 7.10, PO2 of 12.3Kpa, PCO2 of 2.6Kpa, bicarbonate of 8.0mEq/L, and lactate of 2.3mmol/L. His biochemistry results show a sodium level of 145 mmol/L, potassium level of 3.8 mmol/L, chloride level of 105 mmol/L, urea level of 11 mmol/L, creatinine level of 113µmol/L, glucose level of 5.7mmol/L, and serum osmolality of 358 mOsm/Kg. His ethanol level is <10 mmol/L, and his paracetamol level is 0 mg/dl. What is the most likely cause of this 28-year-old mechanic’s presentation?