Archives: MRCP Part 2

MRCP2-3590

A 67-year-old man is on day four of his stay in Intensive Care for respiratory failure requiring intubation and ventilation.
His past medical history includes ocular myasthenia, hypertension and newly diagnosed metastatic lung cancer, for which he has recently been started on nivolumab.
He was admitted to the Oncology Ward six days earlier with bilateral ptosis and worsening proximal weakness. He was reviewed by Neurology whereby it was agreed nivolumab had likely caused a myasthenic crisis. He was started on high-dose methylprednisolone with proton pump inhibitor (PPI) cover, and plasma exchange was organised.
On the Intensive Care Unit evening ward round, a drop in haemoglobin to 70 g/l from 85 g/l is noted. Two units of packed red blood cells are prescribed and infused.
At 0300 h that night, he goes into cardiac arrest and exposure reveals a large volume of haematemesis. Despite the team’s best efforts, return of spontaneous circulation is not achieved.
The Registrar asks you to contact the next of kin to break the bad news, as she needs to attend to another patient who is deteriorating and may need intubation. You suspect the next of kin may want to receive an explanation regarding the cause of the bleed.
What is the most appropriate course of action?

MRCP2-3591

A 55-year-old woman complains of dysphasia and incoordination. Upon CT scan, multiple brain metastases are discovered. What is the probable location of the primary cancer?

MRCP2-3592

A 25-year-old asymptomatic woman has been referred to the genetics clinic due to her family history of breast cancer. Her grandmother passed away from the disease at the age of 54, and her mother and older sister have both been diagnosed with breast cancer recently. Despite a breast examination and ultrasound not revealing any concerning findings, what information should she be given regarding her risk of developing breast cancer?

MRCP2-3593

A 55-year-old postmenopausal woman presents for evaluation after being diagnosed with breast cancer. During her annual screening mammogram, it was discovered that she has dense breasts with microcalcifications measuring 1.3 cm in the left breast, but no associated mass was found. A stereotactic biopsy revealed infiltrating ductal carcinoma that is grade 2 and negative for oestrogen receptor, progesterone receptor, and HER-2. The patient’s family history includes a maternal aunt who was diagnosed with breast cancer at the age of 49. The patient is otherwise healthy and her physical examination is normal. What is the most appropriate next step in management?

MRCP2-3594

Cystic Fibrosis (CF) is an autosomal recessive disease that requires two abnormal alleles to be present for the disease to manifest. If one parent is a carrier (with one abnormal gene), they have a 1:2 chance of passing the abnormal gene to their offspring. Assuming the other parent is of the same genetic stock as those in the area of their birth, the chance of the child receiving an abnormal allele from both parents is calculated by multiplying the male risk (1/2), the female carrier risk (1/20), and the female risk of passing a gene on (1/2), resulting in a 1/80 chance of the child having CF. Other answer options include a 1/4 risk if both parents are confirmed carriers, a 1/40 risk if one partner is a homozygote for the abnormal gene and the carrier frequency is 1 in 20, a 1/160 risk if the carrier frequency is 1 in 40, and a 1/320 risk if the carrier frequency is 1 in 80.

MRCP2-3595

A 65-year-old man is diagnosed with colorectal cancer and undergoes successful resection. However, after receiving six doses of adjuvant capecitabine, he experiences severe diarrhoea, weakness, and desquamation of the hands, feet, and face. He is admitted to the hospital with pancytopenia and electrolyte abnormalities requiring IV replacement. The following are his initial blood test results:

– Na+ 140 mmol/l
– K+ 3.6 mmol/l
– Urea 9.2 mmol/l
– Creatinine 125 µmol/l
– Hb 75 g/l
– Platelets 35 * 109/l
– WBC 0.4 * 109/l
– Neutrophils 0.03 * 109/l
– Adjusted Ca2+ 1.5 mmol/l
– Mg2+ 0.32 mmol/l
– Glucose 4.0 mmol/l

What is the most likely cause of his symptoms?

MRCP2-3578

A 42-year-old man comes to the clinic complaining of blurred vision while reading for the past few weeks. He first noticed this issue during a business trip to Germany a few years ago. He has no significant medical history and is only taking an over-the-counter pain reliever as needed.

During the examination, the left pupil is slightly larger than the right, and the reaction to light is greatly reduced, although it reacts better to accommodation. Tendon reflexes are absent, and plantars are down-going. Peripheral sensation is normal.

What is the most probable diagnosis?

MRCP2-3580

A 59-year-old man presents with severe dyspnoea at rest. He has a past medical history of motor neurone disease which was diagnosed 9 months ago. On examination his chest sounds clear. His respiratory rate is 20 breaths per minute with a shallow depth.

You perform an arterial blood gas which is as follows:

PaO2 7.1 kPa
PCO2 6.3 kPa
pH 7.32
HCO3 38 mmol/l

What is the appropriate management for this patient?

MRCP2-3582

A 35-year-old migrant from Asia is referred for evaluation after a routine health check by her primary care physician. The referral notes ‘possible neurological abnormality’. She has no significant medical history, but reports a past history of working in a factory.

During the examination, you observe that her right pupil is dilated and sluggish responsive to light – both direct and consensual. Ankle reflexes are absent, even with reinforcement. Plantar reflexes are flexor.

What is the probable underlying diagnosis?

MRCP2-3583

A 53-year-old man arrives at the emergency department complaining of a persistent headache that worsens when bending down and in the morning. The headache has been ongoing for a month, and the patient has no medical history or regular medication use.

A CT scan of the head is ordered, revealing a large mass lesion on the right side that is causing displacement of the uncus of the temporal lobe under the tentorium cerebelli.

What is the earliest clinical sign that can be expected to be abnormal based on the patient’s presentation?