Archives: MRCP Part 2

MRCP2-0615

A 40-year-old woman presents to the Emergency Department (ED). She is accompanied by her husband who explains that his wife has been acting irrationally for several weeks. He explains that she is rarely able to sleep, is constantly “on-edge” and has been having recurrent nightmares. She appears often not know where she is, sometimes thinks that she is in the hospital. She appears to be in a daze or a dream state. He explains that roughly six months before her presentation to the ED, she had been pregnant. In the final trimester of pregnancy, a number of complications led to a late termination of pregnancy, sepsis following retained products of conception, and several weeks in intensive care followed by a slow recovery. You suspect that she has post-traumatic stress disorder (PTSD). She has not returned to her place of work since the incident and is on extended sick leave. She has been regularly visited by her friends and family.
What patient characteristics increase the likelihood of PTSD?

MRCP2-0616

A 28-year-old woman visits the Clinic. She has a history of alcohol abuse and has just found out that she is pregnant. The patient is worried about the potential harm her alcohol use could cause to the baby. What guidance would you provide her?

MRCP2-0617

A 50-year-old man presents to the emergency department with complaints of sudden palpitations that started 2 hours ago. He has no medical history and is not on any regular medication. An ECG reveals atrial flutter with 2:1 block. His vital signs are as follows: oxygen saturation of 97% on room air, heart rate of 150 bpm, respiratory rate of 22/min, blood pressure of 105/78 mmHg, and temperature of 36.8ºC. Which of the following treatments should be avoided?

MRCP2-0618

A 50-year-old man was discovered unconscious at his residence by his partner, surrounded by empty packets of flecainide, codeine, and valerian root tablets. His partner became concerned when he locked himself in his room and did not make any noise for four hours. The man had been experiencing depression for the past few months, and his relationship with his partner had been strained. He has a medical history of hypertension, angina, paroxysmal atrial fibrillation, and back pain.

During the examination, the man was lethargic, unable to provide a history, and had a heart rate of 50 bpm, a respiratory rate of 16 breaths per minute, an oxygen saturation of 96% on air, and a blood pressure of 110/58 mmHg. His pupils were equal and reactive to light, measuring 3mm.

The following are the results of the investigations:

– Na+ 136 mmol/l
– K+ 4.6 mmol/l
– Urea 10.9 mmol/l
– Creatinine 110 µmol/l
– Serum bilirubin 30 µmol/l
– Serum alkaline phosphatase 135 IU/l
– Serum aspartate aminotransferase 50 IU/l
– C Reactive protein 2 mg/l
– Haemoglobin 14.6 g/dl
– White cell count 5.6 x 109/L
– INR 1.4

ABG (on air):

– pH 7.258
– pO2 11.7 kPa
– pCO2 3.4 kPa
– Lactate 1.6 mmol/l
– Base Excess -8.4 mmol/l
– Bicarbonate 11.9 mmol/l

The ECG revealed bradycardia with widened QRS complexes and giant inverted T waves.

After fluid resuscitation, what is the next most crucial step in management?

MRCP2-0619

A 79-year-old man comes in for his Warfarin Clinic appointment. He reports feeling well, except for recently being diagnosed with depression, for which he has started cognitive behavioural therapy and medication. His medical history includes persistent atrial fibrillation due to an NSTEMI five years ago. He takes metoprolol, aspirin, warfarin, ramipril, and atorvastatin regularly and has been following the recommended diet for his warfarin intake.

During the examination, the patient appears slim and healthy. His blood pressure is 132/86, and his pulse is irregularly irregular at a rate of 88 bpm. The following investigations were conducted:

– Hemoglobin: 128 g/L (130-180)
– White cell count: 6.7 ×109/L (4-11)
– Platelets: 320 ×109/L (150-400)
– Serum sodium: 139 /L (137-144)
– Serum potassium: 4.5 /L (3.5-5.0)
– Serum urea: 4.7 /L (2.5-7.5)
– Serum creatinine: 72 Umol/L (60-110)
– INR: 5.3 (2.0-3.0)
– LFTs: Normal

Which medication is most likely responsible for the patient’s increased INR?

MRCP2-0620

A 41-year-old man presents to the emergency department with complaints of headache, nausea, and blurred vision. He has a history of alcohol dependency and is currently homeless. He smokes 20 cigarettes per day and drinks at least one bottle of vodka daily. He occasionally obtains alcohol from other homeless individuals.

Upon examination, his heart rate is 111 beats per minute, respiratory rate is 28/minute, oxygen saturation is 97% on room air, blood pressure is 123/77 mmHg, and temperature is 37.1ºC. He appears intoxicated and his abdomen is mildly tender but soft with present bowel sounds. Neurological examination is difficult, but there is some blurring of vision and dilated pupils. Staining of the eye shows no epithelial defect.

Venous blood gas results show a pH of 7.31 (7.35-7.45), HCO3 of 15 mmol/L (22-26), lactate of 2.8 mmol/L (0-2), potassium of 4 mmol/L (3.5-5.5), sodium of 138 mmol/L (135-145), and Cl- of 96 mEq/L (98-106).

What is the most appropriate medication regimen for this patient’s likely diagnosis?

MRCP2-0621

A 50-year-old man is brought to the Emergency department after a house fire. The ambulance crews report that he was initially agitated and confused with tachycardia and hypertension, along with vomiting at the scene. However, he has become increasingly drowsy and confused. On arrival, his blood pressure is 85/60 mmHg, his pulse is 38 beats per minute, respiratory rate is 10 breaths per minute, and there are inspiratory crackles throughout on auscultation. His skin is flushed, and there is incomprehensible moaning on abdominal palpation. Oxygen and IV fluids are started, and a venous blood gas reveals a metabolic acidosis with a marked elevation in serum lactate.

What is the most appropriate intervention for this patient?

MRCP2-0622

A 23-year-old male is rushed to the Emergency Department after collapsing at a party. Upon arrival, he has a GCS of 3/15 and is immediately intubated and ventilated by the Emergency Physicians.

Upon examination, he has a normal body temperature. His heart rate is mildly bradycardic at 54 bpm and his blood pressure is 110/70 mmHg. Both of his pupils measure 2mm. The medical team administers 400 micrograms of naloxone through IV access, but it has no effect. The on-call radiologist is contacted, and a CT head scan is scheduled.

An hour later, the patient unexpectedly extubates himself. He is referred to medicine as his GCS is still 13/15. The CT scan shows no signs of acute intracranial pathology. By the time you arrive in the Emergency Department, his GCS has improved to 15/15, and he is insisting on leaving.

Which drug is the most likely cause of his collapse?

MRCP2-0623

A 72-year-old man presents with increasing ankle swelling, which is causing discomfort and affecting his quality of life. He is currently taking amlodipine 10mg once daily and losartan 75 mg once daily for his blood pressure, which is currently 128/73 mmHg in clinic. On examination, he has pitting edema in the ankles but no other abnormalities. He recently had a normal chest radiograph and echocardiogram showing good systolic function. What steps would you take in managing this patient’s symptoms?

MRCP2-0624

A 45-year-old woman with systemic lupus erythematosus is undergoing pulsed cyclophosphamide infusions for an exacerbation of neuropathy. However, a day after her latest infusion, she experiences suprapubic discomfort and dysuria, and her urine appears pink. A urine dipstick reveals 3+ blood, 1+ leukocytes, 2+ protein, and negative nitrites. What medication can be given with cyclophosphamide to decrease the likelihood of this side effect?