Archives: MRCP Part 2

MRCP2-4696

A 35-year-old male executive presents to you after being referred from the Emergency department. He has been experiencing a painful and swollen left knee for the past 24 hours. He denies any history of joint problems or trauma. Additionally, he has noticed redness and soreness in both eyes over the last two days. He is a non-smoker, married, and consumes about 10 units of alcohol weekly. He recently returned from a business trip to Amsterdam two weeks ago.

During examination, his temperature is 38.5°C, and he has a brown macular rash on the soles of his feet. His left knee is hot, swollen, and tender to palpate, while no other joint appears to be affected.

Investigations reveal Hb 129 g/L (130-180), WBC 14.0 ×109/L (4-11), Platelets 200 ×109/L (150-400), ESR 75 mm/hr (0-15), Plasma sodium 140 mmol/L (137-144), Plasma potassium 4.1 mmol/L (3.5-4.9), Plasma urea 5.6 mmol/L (2.5-7.5), Blood cultures with no growth after 48 hours, and Urinalysis with no blood, glucose, or protein detected. Knee x-ray shows soft tissue swelling around the left knee.

What is the most likely diagnosis?

MRCP2-4697

A 45-year-old man is stable on warfarin therapy for the treatment of atrial fibrillation. He recently went on a trip to Spain for a bachelor party and now complains of scrotal pain and itching. During his trip, he was prescribed ciprofloxacin for a presumed urinary tract infection. After two weeks, he presents to the emergency department with a hot, red, swollen, and painful knee. Additionally, both of his elbows are inflamed and painful on movement. On examination, there is localised tenderness in the knee and painful movement in all directions. The knee is red and hot, and both elbows are mildly warm with painful flexion and extension. He also has red conjunctiva. Although he is afebrile, there is evidence of excoriation around the scrotum. What is the likely cause of his knee pain?

MRCP2-4698

You review a 54-year-old man who complains of persistent bone pain. Bone scanning indicates activity particularly affecting the femurs. You discuss treatment options including bisphosphonate therapy. He has no other medical conditions and no family history of bone conditions or malignancy. The patient has been studying the condition on the Internet and is worried about possible risk of osteogenic sarcoma.
What factors increase the risk of osteogenic sarcoma?

MRCP2-4699

A 65-year-old patient with sero-positive erosive RA is currently being treated with methotrexate (20 mg/week) and sulfasalazine (1 gram bd) but still experiences active inflammatory arthritis. The patient has decided to try abatacept as a biological agent. What is the mechanism of action of abatacept?

MRCP2-4700

A 56-year-old patient presents to rheumatology with a complaint of bothersome dry eyes and dry mouth for the past year. The patient has a medical history of coeliac disease and adheres to a gluten-free diet. On examination, dry oral mucosa is noted, but there are no other significant findings. Blood tests reveal a positive antinuclear antibody and an elevated ESR. What is the most conclusive method for confirming the probable diagnosis?

MRCP2-4684

A 53-year-old man visits his GP with complaints of difficulty rising from his low sofa. He also reports experiencing pain and tenderness in his thigh muscles and shoulder girdle. Upon further inquiry, he admits to having shortness of breath during exercise and a chronic cough. During the examination, the man’s proximal muscle weakness and interstitial lung disease are evident due to his obesity. His CK level is 1050 U/l (24–195), ESR is elevated, and anti-Jo-1 antibodies are positive. What is the most appropriate diagnosis for this clinical presentation?

MRCP2-4685

A 49-year-old woman presented with acute breathlessness that had developed over the past 24 hours. She had been experiencing progressive weakness, dysphagia, and an 8 kg weight loss for the past three months. She was a non-smoker. During the examination, her temperature was 38.4°C, pulse was 96 beats per minute, and blood pressure was 136/65 mmHg. Coarse inspiratory crackles were heard at the right base and mid zone. The patient had grade 4/5 weakness of the proximal muscles of the upper and lower limbs, but no other abnormalities were detected.

Lab results showed:
– Hb: 130g/l (115-165)
– Platelets: 238 * 109/l (150-400)
– WBC: 16 * 109/l (4.0-11.0)
– CRP: 130 mg/l (<10)
– Na+: 140 mmol/l (135-145)
– K+: 3.7mmol/l (3.5-4.5)
– Urea: 7.5 mmol/l (5.0-9.0)
– Creatinine: 98µmol/l (60-11)
– Creatine kinase: 5230U/l (24-170)

What diagnostic test or procedure is most likely to provide a specific diagnosis?

MRCP2-4692

A 44-year-old woman presents with a complaint of proximal muscle weakness that has been ongoing for 8 months. She has no significant medical history and is not taking any medications or consuming alcohol. Upon examination, she exhibits 4/5 power proximally in both arms and legs, with no other notable findings. Blood tests are unremarkable except for an elevated creatinine kinase level of 900 U/L. Electromyography reveals myopathic features, and a muscle biopsy is ordered to aid in identifying the specific myopathy. The biopsy results indicate endomysial lymphocytic infiltrates invading non necrotic muscle fibers. What is the most probable diagnosis?

MRCP2-4693

A 42-year-old man presents with a one month history of painful and swollen distal interphalangeal joints in his right hand index and middle finger. He reports a few previous episodes of finger swelling in his left hand that resolved within a week. He drinks 6 units of alcohol per week and recently returned from a trip to the USA. There is no significant medical history except for his sister having psoriasis. On examination, the distal interphalangeal joints in his right hand index and middle finger are swollen and tender. His recent blood test shows a haemoglobin level of 130 g/L (130-180), WBC count of 10.9 ×109/L (4-11), neutrophil count of 6.8 ×109/L (1.5-7), and an ESR of 45 mm/hr (0-15). Urea, electrolytes, and creatinine are normal, and rheumatoid factor is negative. What is the most likely diagnosis?

MRCP2-4694

You see a 28-year-old patient with a swollen left knee. It has been getting worse for a number of months and is now affecting her ability to work as a nurse. The pain and stiffness are worse overnight and in the morning and gets better throughout the day. She denies any trauma or fever. She also has some pain and stiffness in her toes which is also worse in the morning. Her joints are worse after rest.

She is normally fit and well and denies any previous joint problems or psoriasis. However, her mother has a history of psoriasis. She says there is no family history of joint problems to her knowledge.

On examination, her knee is red, warm and tender to palpate. There is a moderate knee effusion and flexion is limited due to pain. Her distal interphalangeal joints (DIPs) are tender and slightly swollen.

There are no skin rashes. Although her knee is painful the patient looks well and has a heart rate of 80 beats per minute and her temperature is 36.8ºC.

Blood tests reveal a raised CRP at 85 but a negative rheumatoid factor.

What is the most likely diagnosis?