Archives: MRCP Part 2

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?

MRCP2-4660

A 26-year-old patient with a history of psoriasis complains of arthralgia. The patient reports experiencing swelling in her knuckles and worsening psoriasis symptoms over the past four months. Upon examination, severe plaque psoriasis is observed on the patient’s extensors and scalp, resulting in alopecia. The metacarpophalangeal joints are visibly swollen and tender. The patient is currently taking naproxen 500mg BD, paracetamol 1g TDS, and using topical steroids and calcipotriol. What additional medication would you recommend?

MRCP2-4661

A 56-year-old woman with RA has been taking methotrexate for six weeks and has seen significant improvement in her joint symptoms. However, she has developed a dry cough, shortness of breath, and fever over the past three days. Her current medications include methotrexate, folic acid, and aspirin, and she has no personal or family history of chronic illnesses. On examination, she has synovitis in both wrists and MCPJs, and scattered crepitations in her respiratory system. Blood tests show elevated ESR and patchy airspace shadows are seen bilaterally on her CXR. What is the most likely diagnosis?

MRCP2-4662

A 57-year-old man comes to his doctor for evaluation. He has been experiencing increased bone pain in his lower back and pelvic area for the past few months. He was diagnosed with some hearing loss two years ago. Blood tests show normal calcium levels but elevated alkaline phosphatase. X-rays reveal skull features consistent with Paget’s disease, and bone scanning shows increased activity in the lumbar vertebrae and pelvis. The doctor starts him on bisphosphonate therapy.
What is the most appropriate method to monitor disease activity in this man?

MRCP2-4663

A 35-year-old woman with a history of systemic lupus erythematosus and stable joint disease managed with hydroxychloroquine presents to the nephrology clinic with complaints of worsening peripheral edema. On examination, she has a blood pressure of 159/88 mmHg, a regular pulse of 78 beats per minute, and pitting edema in both lower limbs. Her laboratory results show a sodium level of 141 mmol/l, potassium level of 5.1 mmol/l, urea level of 8.1 mmol/l, creatinine level of 159 µmol/l, and urinary protein level of 5 g/24hrs. What is the most appropriate intervention for long-term renal outcomes?

MRCP2-4664

A 67-year-old male smoker presents with progressive difficulty in walking long distances. He also has trouble lifting heavy objects.
He has 4/5 power proximally, with intact reflexes and downward going plantars.
Dermatomyositis was diagnosed based on the following blood tests, and muscle biopsy:
Hb 118 g/L (130-180)
WBC 7.2 ×109/L (4-11)
Neutrophils 80% (40-75)
Platelet 190 ×109/L (150-400)
ESR 70 mm/hr (0-20)
CK 250 IU/L (24-195)
CRP 140 mg/L (<10)
Urea, electrolytes and creatinine are normal. CXR is also normal.
Anti-nuclear antibody negative 1:12800
Anti-ENA antibody negative
What is the most appropriate next investigation?

MRCP2-4665

A 55-year-old man, who has a history of heavy smoking, presents with a gradual onset of weakness and fatigue over the past 8 months. He has noticed difficulty in climbing stairs and complains of a dry mouth and feeling light-headed when standing. Symptoms are worse in the evening. On examination, there is mild proximal weakness in the lower limbs with absent reflexes. Nerve conduction studies show low-amplitude motor responses that normalise after a brief 10 s maximal isometric contraction, increasing two to threefold in amplitude. What is the probable diagnosis?

MRCP2-4666

A 50-year-old woman with rheumatoid arthritis (RF positive, anti-CCP positive) presented with multiple well-defined ulcers on her legs. She is currently taking methotrexate 20 mg/week, folic acid 5 mg/day, and sulfasalazine 1 gm/day, and her arthritis is well controlled with no swollen or tender joints. However, her recent blood tests showed leucopenia, and both methotrexate and sulfasalazine were stopped for two weeks. Despite this, repeat blood tests did not show any improvement in her WBC count. Further investigations revealed a negative anti-nuclear antibody and the following results: Hb 129 g/L (115-165), WBC 1.4 ×109/L (4-11), Neutrophils 39% (40-75), Platelet 166 ×109/L (150-400), ESR 26 mm/hr (0-30), and CRP 13 mg/L (<10). What is the most likely diagnosis?

MRCP2-4667

A 29-year-old woman presents to rheumatology with a one-year history of painful hands that change colour in cold weather. She reports a white, blue, and then red discoloration followed by symptom resolution. She denies any other symptoms or medical history. On examination, her hands are blue-white and cool to touch, but there is no ulceration or scarring. Blood tests are negative for autoimmune and infectious causes. What is the recommended initial pharmacological management for this likely diagnosis?

MRCP2-4637

A 75-year-old retired sea captain presents with weakness in his shoulders and hips that has been progressing over the past four months. He has also noticed weakness in his finger flexors, but normal strength in straightening them. Additionally, he has experienced difficulty swallowing liquids. The patient has no significant medical history, except for a sexually transmitted disease he contracted in the South Pacific 40 years ago, which was treated with antibiotics. He is unsure of the diagnosis. He smokes a pipe and drinks one or two tots of rum on the weekends. His creatine kinase level is 120. What diagnostic test is most likely to provide a definitive diagnosis?