Archives: MRCP Part 2

MRCP2-4635

An 80-year-old woman presents to the rheumatology outpatient clinic with a history of Giant Cell Arteritis diagnosed 3 years ago. Despite being on prednisolone 8 mg, she has been unable to taper down the dose due to excruciating temporal headaches, weakness, and fatigue. Previous attempts to lower the dose have resulted in mild visual loss, requiring hospitalization. She is also on zoledronic acid for osteoporosis, with recent vertebral fractures. Concerned about the side effects of steroids, including diabetes and weight gain, she asks about alternative treatment options for her condition. What are the available management options for this patient’s Giant Cell Arteritis?

MRCP2-4606

A 50-year-old woman comes in for a check-up. Her mother was recently hospitalized due to a hip fracture, and she is worried that she may have inherited osteoporosis. She has no significant medical history, does not take any regular medication, and has never experienced any fractures. She is a smoker, consuming around 20 cigarettes per day, and drinks 3-4 units of alcohol daily.

What would be the best course of action in this situation?

MRCP2-4607

A 67-year-old woman presents to the oncology clinic for follow-up. She has advanced breast cancer that is estrogen receptor positive and HER2 negative, with metastasis to her ribs, thoracic vertebrae, and right humerus. She previously underwent a right mastectomy and received first-line chemotherapy, but has declined further chemotherapy.

The patient has been experiencing back and rib pain, which was relieved by external beam radiotherapy. She was prescribed alendronate to prevent pathological fractures, but has been suffering from nausea, severe acid reflux, and epigastric discomfort that was not alleviated by a proton pump inhibitor. Alendronate was discontinued, and risedronate was tried, but it had similar effects and was also stopped.

What is the most appropriate medication to prescribe to prevent skeletal-related events in this patient?

MRCP2-4608

A 23-year-old female patient visits her GP complaining of persistent fatigue and widespread body pains. She used to be an enthusiastic athlete, but now experiences frequent ankle sprains and has a history of recurrent right shoulder dislocation. During the physical examination, the doctor observes that her skin is soft and stretchy, and she displays joint hypermobility in various joints. What additional ocular manifestation is commonly linked to this disorder?

MRCP2-4609

A 48-year-old woman presents with a three-week history of finger pain. She has noticed her hands getting extremely cold and turning a strange color when outside. Upon returning inside, her hands are very painful as they warm up. She has previously managed this with gloves, but now has developed ulcers on her fingertips. She also complains of epigastric pain and has had shortness of breath for some time. Her medical history includes pulmonary fibrosis and hypertension, and she takes propranolol, amlodipine, simvastatin, and omeprazole.

During examination, the skin over her hands is dry and shiny, and there is severe digital ulceration on three fingertips of the left hand. The fingertips are dusky in color and extremely tender. The skin over the upper arms and chest appears normal. Upon auscultation of the lungs, there are fine bibasal inspiratory crepitations that do not change upon coughing. Heart sounds are normal with no added murmurs, but there is a left ventricular heave.

What is the most appropriate management plan for this patient?

MRCP2-4610

A 60-year-old woman with idiopathic Raynaud’s presents to the clinic with concerns about painful, ‘blue’ fingers and early signs of ulceration. Despite trying various over-the-counter medications, heating techniques, and calcium channel blockers, she has not experienced any improvement. The patient also has a history of hypertension and is currently taking Losartan.

During the examination, the patient exhibits prominent acrocyanosis with areas of skin discoloration and moderate digital ulceration. There are no signs of sclerodactyly or telangiectasia. Her blood pressure measures 105/60 mmHg.

What medication options are available to alleviate this patient’s symptoms?

MRCP2-4611

A 25-year-old female patient complains of erythema nodosum, accompanied by low-grade fever and bilateral ankle arthritis. She has no medical history and is not taking any medication. There is no record of her traveling abroad. What would be the most suitable test to conduct for this patient?

MRCP2-4616

A 56-year-old woman with a history of rheumatoid arthritis is currently receiving a weekly dose of 15mg of methotrexate. During her routine check-up, her blood tests reveal a significant decrease in her cell counts, indicating methotrexate induced bone marrow failure.

Hemoglobin: 110 g/l
Platelets: 135* 109/l
White blood cells: 3 * 109/l
Neutrophils: 1.9*109/l

What is the most appropriate course of action for managing this patient’s condition?

MRCP2-4617

A 75-year-old male falls while walking his dog. He experiences severe left hip pain and his left leg is shortened and externally rotated. He is rushed to the Emergency Department where an X-ray confirms a left-sided intracapsular neck of femur fracture. The patient undergoes surgery the next day. What measures should be taken to manage his bone health and reduce the risk of future fragility fractures?

MRCP2-4618

A 50-year-old man presents to rheumatology with severe tophaceous gout. He has been experiencing intermittent gout attacks affecting his first metatarsophalangeal joints for the past few years. However, over the last two months, he has developed inflammation of multiple small joints in his hands, which has prevented him from continuing his work as a train driver. His General Practitioner prescribed Colchicine, but it was discontinued due to severe diarrhoea. The patient’s medical history includes an upper GI bleed from a duodenal ulcer six months ago.

On examination, the patient has severe asymmetrical inflammation of multiple metacarpalphalangeal, distal interphalangeal, and proximal interphalangeal joints in both hands. Yellow-white tophi are present across the inflamed joints. Blood tests taken prior to clinic attendance show:

Hb 15.2 g/dl
Platelets 265 * 109/l
WBC 6.5 * 109/l

Na+ 134 mmol/l
K+ 4.2 mmol/l
Urea 9.5 mmol/l
Creatinine 175 µmol/l
eGFR 62 ml/min
Urate 370 µmol/l

What is the most appropriate treatment for this patient’s acute gout?