Archives: MRCP Part 2

MRCP2-4678

A 54-year-old man presents with reduced sensation in both feet and lethargy. He reports a 2-month history of fevers and a weight loss of 4kg. Additionally, he reports experiencing intermittent testicular pain.

Upon examination, there is livedo reticularis on both legs and reduced light touch and pain sensation on both feet.

Blood tests reveal:

Hb 116 g/l
Platelets 487 * 109/l
WBC 8.3 * 109/l
Neuts 6.3 * 109/l
MCV 89 fL
Na+ 137 mmol/l
K+ 4.8 mmol/l
Urea 12.8 mmol/l
Creatinine 182 µmol/l
Bilirubin 18 µmol/l
ALP 92 u/l
ALT 102 u/l
γGT 16 u/l
ESR 78mm/hr
Albumin 35 g/l

What is the most likely diagnosis?

MRCP2-4679

A 78-year-old man has been referred to your clinic by his doctor due to a complaint of stiffness in his proximal muscles, particularly in the morning, for the past two months. He reports no weakness. What is the most appropriate next step in the diagnostic process?

MRCP2-4680

A 70-year-old woman presents to the emergency department due to difficulty coping at home. She has been experiencing weakness and fatigue for the past month, and has been having trouble getting out of bed. Her arms feel heavy in the morning, and she has been experiencing shoulder pain and reduced appetite. She has a medical history of stroke, atrial fibrillation, heart attack with coronary stenting, and hypertension. Her vital signs are normal except for a temperature of 37.7 degrees. Her joints are not tender or swollen, and her visual acuity is normal. Blood tests reveal a hemoglobin level of 122 g/l, platelet count of 366 * 109/l, white blood cell count of 8.9 * 109/l, sodium level of 137 mmol/l, potassium level of 4.1 mmol/l, urea level of 6.2 mmol/l, and creatinine level of 122 µmol/l. What is the most likely diagnosis?

MRCP2-4652

A 67-year-old woman visits a geriatric clinic due to frequent falls at home. She has never been to the clinic before. Two weeks ago, she had a CT scan of her head, cervical spine, and right hip, which showed no acute injury. However, she has been experiencing worsening pain in her right hip for the past year, especially during activity and in the evenings. On examination, she is tender to deep palpation and experiences painful internal and external rotation. She reports being otherwise healthy, with a medical history of obesity and type 2 diabetes mellitus. Her general practitioner has advised her to lose weight.

What is the most appropriate additional advice for managing her hip pain?

MRCP2-4654

You review a 63-year-old woman in the Rheumatology Clinic, some 6 weeks after her admission for joint pain and swelling. She was commenced on methotrexate after her admission, in addition to other medications including prednisolone 5 mg daily and paracetamol, which she has taken for several years. Since her admission she has been experiencing increasing fatigue, but is complaining of a skin rash and mouth ulcers.
Blood testing reveals the following:
Investigation Result
Anti ds-DNA antibodies Negative
Anti-histone antibodies Positive
C3/C4 levels Normal
You suspect a diagnosis of lupus.
What is the most appropriate course of action?

MRCP2-4655

An 80-year-old woman presents to the Emergency Department with complaints of severe headaches on the left side of her head. She also reports intermittent jaw pain while chewing. Her daughter reports that her mother has been increasingly fatigued over the past few weeks. Laboratory testing shows an ESR of 95 mm/h. What is the best course of action for managing this condition?

MRCP2-4656

A 32-year-old woman visits her family doctor (GP) with complaints of lower back pain, specifically on the lateral lower spine when bending forward. The pain is more severe in the morning. She had to take a break from her job as a nurse six months ago due to an episode of plantar fasciitis.

The following investigations were conducted:

Haemoglobin (Hb) 132 g/l 135–175 g/l
White cell count (WCC) 5.2 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 180 × 109/l 150–400 × 109/l
Neutrophils 3.1 × 109/l 2.5–7.58 × 109/l
Lymphocytes 2.0 × 109/l 1.5–3.5 × 109/l
Erythrocyte sedimentation rate (ESR) 18 mm/hour 1–20 mm/hour
C-reactive protein (CRP) 8.5 mg/l < 10 mg/l
Aspartate aminotransferase (AST) 30 IU/l 10–40 IU/l
Alkaline phosphatase (ALP) 95 IU/l 30–130 IU/l
Alanine aminotransferase (ALT) 22 IU/l 5–30 IU/l
Anti-cyclic citrullinated peptides (Anti-CCP) < 20
Rheumatoid factor (RF) Negative
Anti-nuclear antibody (ANA) Negative

What is the most appropriate initial treatment for this case?

MRCP2-4657

A 65-year-old woman with a history of peptic ulcers and knee osteoarthritis presents with worsening left knee pain over the past week. The pain is exacerbated by walking and climbing stairs, and is severely limiting her mobility. She denies any recent knee injury or swelling. Currently, she is taking co-codamol (30/500 mg) up to four times a day, NSAID gel, and fentanyl patches to manage her pain. On examination, she is found to be overweight and there is crepitus in her right knee, but no effusion is present. What should be the next step in her treatment plan?

MRCP2-4658

A 22-year-old male visits his GP with complaints of muscle cramps that hinder his participation in a 5 km race at the local park. He has always experienced muscle pains during warm-up exercises, but they gradually subside after 20 minutes. There were no signs of weakness or abnormalities during the neurological examination.

The patient’s creatinine kinase levels were elevated at 1215 IU/L, and myoglobinuria was detected during urinalysis. The electromyography (EMG) revealed myotonic discharges and fibrillations.

What is the probable diagnosis?

MRCP2-4659

A 65-year-old man who is being treated with methotrexate for psoriasis has misunderstood the directions for therapy and presents to the clinic with glossitis, severe mouth ulcers and megaloblastic anaemia.

On further questioning, it transpires he has been taking a dose of 30 mg per week, rather than 15 mg per week.

Investigations reveal the following:

Haemoglobin (Hb) – 95 g/l (normal value: 130-180 g/l)

Mean corpuscular volume (MCV) – 110 fl (normal value: 80-100 fl)

White cell count (WCC) – 2.5 × 109/l (normal value: 4.0-11.0 × 109/l)

Platelets (PLT) – 100 × 109/l (normal value: 150-400 × 109/l)

What is the most appropriate rescue medication for this patient?