Archives: MRCP Part 2

MRCP2-4786

A 65-year-old female presents to gastroenterology outpatient clinic with a three-week history of gastric reflux, which has not improved despite being prescribed both ranitidine and omeprazole by her GP. She is awaiting an urgent OGD to investigate symptoms further. She reports having lost 8kg in weight over the past 7 months and is also distressed by appearances of white hard lumps appearing on her fingertips. On examination, you note cool peripheries and dry mucous membranes, left thumb calcinosis surrounded by shiny skin up to her wrist joint and wrinkling of skin around her mouth. Her blood tests are as follows demonstrate she is positive for anticentromere antibodies. What is the most likely diagnosis?

MRCP2-4787

A 50-year-old female presents to the acute medical unit with fever and rigors. She has a medical history of rheumatoid arthritis and is currently taking methotrexate and sulfasalazine. Recently, she was treated with trimethoprim for a urinary tract infection.

Upon examination, her blood results show a hemoglobin level of 110 g/l, platelets at 94 * 109/l, and a white blood cell count of 1.2 * 109/l. Her neutrophil count is 0.6 * 109/l, lymphocyte count is 0.4 * 109/l, and her CRP level is 212 mg/l. Her sodium level is 138 mmol/l, potassium level is 3.8 mmol/l, urea level is 7.8 mmol/l, and creatinine level is 104 µmol/l.

What is the recommended treatment for this patient?

MRCP2-4790

A 56-year-old patient with tophaceous gout is unable to tolerate allopurinol tablets due to hypersensitivity reaction. The patient is considering long-term urate-lowering treatment with febuxostat. What is the mechanism of action of febuxostat?

MRCP2-4788

A 23-year-old woman presents to the physician with a four-week history of daily fevers, a red rash that worsens with the fever spikes, joint pains affecting both wrists, her left knee and her right ankle, and extreme exhaustion. She is unable to keep up with her job as a waitress due to these symptoms. On examination, her temperature is 37.5°C, heart rate is 72/min and regular. There is evidence of pericardial friction rub, and the lungs are clear. You confirm evidence of oligoarthritis.
Investigations;
Investigation Results Normal Value
Haemoglobin (Hb) 122 g/l 135–175 g/l
White Cell Count (WCC) 11.5 × 109/l 4–11 × 109/l
Platelets (PLT) 155 × 109/l 150–400 × 109/l
Sodium(Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Creatinine 90 micromol/l 50–120 µmol/l
Erythrocyte sedimentation rate (ESR) 80 mm/1st hour 0–10mm/ 1st hour
CRP 220 mg/l 0–10 mg/l
Ferritin 600 microg/l 20–250 µg/l
What is the most likely diagnosis?

MRCP2-4785

A 67-year-old man has been referred to rheumatology for advice on managing his gout. He has been experiencing intermittent inflammation of the first metatarsophalangeal joint in both feet for the past decade, with an increase in frequency to 6 episodes in the past year. Recently, his right knee has also become inflamed, with synovial aspirate microscopy showing needle-shaped crystals with negative birefringence.

During acute attacks, the patient has found relief with colchicine and NSAIDs. Allopurinol was previously tried as prophylaxis at a dose of 200 mg daily, but was discontinued due to renal function deterioration. Lifestyle modifications have also been attempted. The patient has type 2 diabetes, hypertension, hypercholesterolemia, and chronic renal failure, and takes ramipril, metformin, and simvastatin regularly.

On examination, the patient is obese and has tophi on his ears, but no current joint inflammation is noted. Blood tests taken prior to clinic attendance show a hemoglobin level of 16.5 g/dl, platelets at 150 * 109/l, and a white blood cell count of 8.6 * 109/l. His electrolyte levels are within normal range, but his urea is at 11.2 mmol/l, creatinine at 190 µmol/l, eGFR at 45 ml/min, and urate at 395 µmol/l.

What is the most effective approach for gout prophylaxis in this patient?

MRCP2-4784

You are evaluating a 22-year-old male patient who has been experiencing inflammatory back pain for the past 3 years. You suspect a diagnosis of ankylosing spondylitis (AS) and order X-rays of the lumbosacral spine and sacroiliac joints, as well as a test for HLA B27. What is the significance of HLA B27 in this context?

MRCP2-4789

A 56-year-old man attends the Gastroenterology outpatient clinic for a follow-up on his Crohn’s disease, which was diagnosed three years ago. He has a medical history of hypercholesterolemia, gout, and ischaemic heart disease. The patient has been experiencing increased abdominal pain and diarrhoea for a few months, and the physician recommends starting azathioprine. Before initiating the medication, what is the crucial medication that needs to be checked if he is taking?

MRCP2-4771

A 65-year-old woman has been referred to the Rheumatology Clinic after experiencing her second Colles’ fracture. DEXA scanning confirms osteoporosis with a T-score of -2.8. The patient is eager to begin preventive treatment.
Based on the following investigations, which initial therapy would be the most appropriate for this patient?

Investigation Result Normal Value
Phosphate (PO43-) 0.9 mmol/l 0.70–1.40 mmol/l
Corrected Calcium (Ca2+) 2.27 mmol/l 2.20–2.60 mmol/l
Alkaline phosphatase (ALP) 180 IU/l 30–130 IU/l
Urea 3.2 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 75 µmol/l 50–120 µmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l

MRCP2-4776

A 37-year-old Armenian tourist presents with a 3-day history of fever, chest pain, abdominal pain, and shortness of breath, accompanied by a temperature of 38.5 degrees. She has no known medical history and has experienced at least two previous episodes of similar pain that resolved spontaneously without treatment or diagnosis. Her mother was recently hospitalized for similar symptoms. On examination, she has a pleural rub and a swollen, tender left 3rd metacarpophalangeal joint. Her blood tests reveal:

– Hb 14.5 g/dl
– Platelets 560 * 109/l
– WBC 17.8 * 109/l
– Na+ 143 mmol/l
– K+ 4.6 mmol/l
– Urea 5.2 mmol/l
– Creatinine 78 µmol/l
– CRP 78 mg/l

A chest X-ray shows mild bilateral pleural effusions with no significant consolidation. Her Mantoux test is negative, and a urine dip and culture are negative. Urinary porphobilinogen is also negative. A rheumatology consultation is requested for the synovitis, and colchicine is prescribed, which results in the resolution of all symptoms within 24 hours. An infectious diseases consultation and induced sputum are pending. What is the most probable diagnosis?

MRCP2-4775

A local GP requests your evaluation of a 40-year-old female patient who has been experiencing symptoms of oesophageal reflux disease that have only partially responded to proton-pump inhibitors. Lately, she has been complaining about the cold weather and may have Raynaud’s phenomenon. During routine blood testing, her creatinine levels were found to be elevated at 180 µmol/l, and she has hypertension with a blood pressure reading of 170/85 mmHg. What is the most effective treatment to prevent further renal impairment?