Archives: MRCP Part 2

MRCP2-4638

A 56-year-old Caucasian teacher with RA started taking adalimumab three months ago and has seen significant improvement in joint symptoms. However, she has been experiencing a dry cough, weight loss, and fever for the past month, resulting in a 10 kg weight loss. She is also taking methotrexate and folic acid, and has no personal or family history of chronic illnesses. On examination, she has scattered crepitations in her respiratory system and cervical lymphadenopathy. Recent blood tests show elevated ESR and miliary shadows bilaterally on CXR. What is the most likely diagnosis?

MRCP2-4640

A 43-year-old teacher presents with complaints of joint pains and occasional swelling of the wrists and knees for the past two months. She has been taking ibuprofen to alleviate the symptoms. However, her knee pain has worsened and her fingers are more stiff and sore. She also noticed a rash on her legs a month ago, which subsided after 10 days but has reappeared recently. Additionally, she has developed painful purple lesions on her ankles. She has been experiencing low-grade fevers, muscle aches, and recurrent headaches for the past two weeks. She has missed several days of work due to flu-like symptoms and has also experienced abdominal pain, nausea, and vomiting for the past two days. On examination, she appears unwell with mild right upper quadrant tenderness and palpable purpuric lesions on her legs. Her investigations reveal abnormal blood counts, elevated ESR, and abnormal liver function tests. What test would be most helpful in establishing the diagnosis?

MRCP2-4641

A 43-year-old nurse who works in a liver transplant unit presents with complaints of joint pains and occasional swelling of the wrists and knees for the past two months. The pain is relieved by ibuprofen, but her knee pain has worsened and her fingers are more stiff and sore. She also reports a rash on her legs that looks like ‘blood blisters’ and painful purple lesions on her ankles. Additionally, she has been experiencing low-grade fevers, muscle aches, recurrent headaches, and has noticed some weight loss. On examination, she appears ill with mild swelling and tenderness of both wrists and small bilateral knee effusions. Discrete palpable purpuric lesions are noted on her legs with a few tender haemorrhagic lesions over both ankles. Investigations reveal abnormal blood work, including elevated ESR, plasma bilirubin, and plasma aspartate transaminase levels, as well as the presence of blood, protein, and red and white blood cells in her urine with granular casts detected. What is the most likely diagnosis for this patient?

MRCP2-4642

A 75-year-old retired teacher with no past medical history presents to the hospital with a 6-month history of muscle aches and weakness. She also has difficulty swallowing and has had 3 courses of antibiotics for a presumed chest infection in the last 3 months. In the last 2 days she has been struggling to cope at home and has had two falls.

Blood tests show:

Erythrocyte Sedimentation Rate (ESR) 60 mm/hour g/l
Creatinine Kinase 8000 U/L

Which of the following investigations would be LEAST helpful in the workup?

MRCP2-4643

A 30-year-old woman with a history of rheumatoid arthritis seeks advice on starting a family with her partner. Her rheumatoid arthritis is currently well-managed with methotrexate and sulphasalazine, and she has not needed to adjust her doses for the past two years. However, she is hesitant to stop taking her medications unless it is necessary, as she experienced several flares when her doses were reduced three years ago. What recommendations would you provide regarding her pregnancy plans?

MRCP2-4644

A 29-year-old female presents with increasing fatigue. She also complains of joint pains affecting several joints. There is associated joint stiffness lasting about 20-30 mins. She also gets a skin rash, especially in sun-exposed areas. There is no significant past medical history and she is not using any regular medications. She works as an office clerk and the joint pains are making it difficult for her to continue her work normally. Following are the results of her investigations:

Hb 9.3 g/l Na+ 136 mmol/l Bilirubin 98 µmol/l
Platelets 99 * 109/l K+ 4.2 mmol/l ALP 89 u/l
WBC 7.3 * 109/l Urea 4.5 mmol/l ALT 23 u/l
Neuts 3.4 * 109/l Creatinine 87 µmol/l γGT 43 u/l
Lymphs 2.7 * 109/l CRP <1 mg/l Albumin 32 g/l
Eosin 0.2 * 109/l C3, C4 low

Chest x-ray and ECG were normal. Urine exam showed protein +++.

What is a characteristic feature of the underlying condition in this patient?

MRCP2-4645

A 65-year-old male with a history of lumbosacral polyradiculopathy due to neurosarcoidosis is currently on high dose steroids and methotrexate for several months. He is admitted to the hospital with breathlessness and a dry cough, and is diagnosed with type 1 respiratory failure and Pneumocystis jirovecii pneumonia based on a CT chest scan. The microbiology team recommends treating him for bacterial pneumonia and viral pneumonitis as well. Considering his current medications, which of the following drugs could potentially lead to a life-threatening interaction?

MRCP2-4646

A 75-year-old woman presents to the Rheumatology Clinic with a 3-week history of bilateral hip pain and malaise. The pain is diffuse and affects the anterior and posterior aspects of the pelvis as well as the upper thighs. It is worse in the mornings and accompanied by stiffness that takes several hours to improve. She also reports a constant right-sided headache for the past 2 weeks and a recent episode of transient visual darkening, although she cannot recall which eye was affected. Her medical history includes hypertension and hypothyroidism, and she takes amlodipine and levothyroxine regularly. On examination, her visual acuity is 6/9 in both eyes, and her right temporal artery pulsation is difficult to feel. Blood tests show elevated CRP levels. A temporal artery biopsy is negative for giant cell arteritis. What is the best treatment approach?

MRCP2-4647

A 42-year-old woman presents with fatigue, loss of appetite, gradual weight loss, and occasional chest pain. She also reports a rash on her nose and cheeks that worsens in the summer and joint pain in her wrists, knees, and ankles. On examination, her blood pressure is 150/94 mmHg, and she has a facial rash. Her test results show a low hemoglobin level, low white blood cell count, low platelet count, prolonged partial thromboplastin time, elevated C-reactive protein, high sodium and potassium levels, elevated creatinine, and blood and protein in her urine. What is the most specific test to determine her underlying diagnosis?

MRCP2-4648

A 40-year-old woman presents to the Pulmonary Clinic with complaints of a persistent cough and increasing shortness of breath on exertion over the past three years. She has a history of smoking five cigarettes per day and occasional alcohol consumption. She reports normal bowel movements but has noticed increased urination and thirst over the past eight months. The patient also complains of back pain and difficulty bending forward for the past six months.

Upon examination, bilateral crepitations were heard in the upper regions of both lung fields. Her blood pressure is 120/80 mmHg and her heart rate is 96 bpm. Oxygen saturation on room air was 94%.

Which diagnostic test would confirm the diagnosis in this patient?