Archives: MRCP Part 2

MRCP2-4602

A 50-year-old female presents with severe lower back pain. She reports that the pain began a few months ago and has progressively worsened. She has also been experiencing weight loss, fevers, and rigors. Upon examination, there is severe tenderness upon palpation over the L4 vertebrae, but no associated neurological signs are present.

The following blood results were obtained:

– Hb: 105 g/l
– Platelets: 542 * 109/l
– WBC: 20.2 * 109/l
– Neuts: 15.4 * 109/l
– Lymphs: 2.2 * 109/l
– Na+: 140 mmol/l
– K+: 3.8 mmol/l
– Urea: 8.5 mmol/l
– Creatinine: 92 µmol/l
– CRP: 288 mg/l

What diagnostic test is most likely to confirm the diagnosis?

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?

MRCP2-4603

A 35-year-old Hispanic woman presented with a 3-week history of fever and chills followed by a widespread papular rash over her body. Two weeks ago, she noticed that her elbow and knee were swollen and tender. The inflammation resolved a few days later, but now her left ankle is very swollen and tender and she can barely weight-bear on it. She works as a nurse and she was in Mexico until 3 weeks ago on a vacation.
On examination, her left ankle is hot and swollen and there are a few vesicular lesions on her face.
Investigations reveal the following:

Haemoglobin (Hb) 142 g/l 135–175 g/l
White cell count (WCC) 12.5 × 109/l 4.0–11.0 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5 mmol/l
Creatinine (Cr) 92 μmol/l 50–120 μmol/l
Rheumatoid factor (RF) Negative
Antinuclear antibody (ANA) Absent
Synovial fluid white cells > 15 000/μl
What is the likely diagnosis?

MRCP2-4604

A 22-year-old male presents with a 5-day history of joint pain in both his ankles, left 3rd metacarpal-phalangeal (MCP) joint and right elbow; blood in his urine and a new rash on his forehead, which particularly bothers him. He also complains of chest pain of non-specific nature, onset about one week ago.

On examination, you note bilateral swollen MCP joints, a hyperpigmented, raised erythematous rash on his forehead. Neurological examination reveals a mild distal tremor at rest and activity, with bilateral Kayser Fleischer rings. He was diagnosed with Wilson’s disease aged 20 years old and has no other past medical history.

He is currently a research assistant and lives alone. His medications include ibuprofen as required, penicillamine started on diagnosis 2 years ago and he states he has been buying zinc supplements over the counter after reading in a journal that it may be helpful for his condition. Urine dip demonstrates 3+ blood, 1+ protein, no leucocytes or nitrites.

Which blood test is most likely to be diagnostic of his most recent admission?

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?

MRCP2-4616

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?

MRCP2-4612

A 16-year-old Arabic male presents with a high temperature, abdominal pain, and a fixed erythematous rash on his ankle. Upon examination, his abdomen is tender, but other systems appear normal. Upon questioning, he admits to several similar episodes in the past that have resolved spontaneously after three to seven days. Blood tests reveal leukocytosis, neutrophilia, high ESR, CRP, and a normal UE&C, amylase, and LFTs. A mild polyclonal increase in serum immunoglobulin is also present. A chest x-ray is normal, and a CT scan of the abdomen reveals a scanty amount of free fluid. Recent blood tests show Hb 111 g/L (130-180), WBC 18.8 ×109/L (4-11), Neutrophils 90% (40-75), Lymphocytes 10% (20-45), Eosinophils 30% (1-6), Platelet 270 ×109/L (150-400), ESR 86 mm/hr (0-15), and CRP 143 mg/L (<10). What is the diagnosis?

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?

MRCP2-4615

A 60-year-old woman presents to the rheumatology clinic with complaints of increasing joint pain and stiffness despite being on a combination of methotrexate, folic acid, and azathioprine for her rheumatoid arthritis. She has also been experiencing fatigue and respiratory tract infections, as well as easy bruising. On examination, she appears well but has a mass in the left upper quadrant of her abdomen. Her joint examination is unremarkable. Her recent blood work shows a low hemoglobin, low platelets, and low white blood cell count with a predominance of eosinophils. Her liver function tests are mildly elevated. What is the most likely cause of her symptoms and abnormalities?

MRCP2-4601

A 30-year-old Caucasian farmer presents to the outpatient department with a complaint of generalised aches and pains that have been bothering him for the past two months. He used to be an active runner but had to give up competitive running a year ago due to a hip injury. Two years ago, he had a painful red eye for which he received treatment with eye drops in the Emergency department. He is a heavy smoker, consuming 45 cigarettes a day, and drinks five pints of beer every weekend. He denies any skin rashes or mucosal ulceration. His mother had rheumatoid arthritis, and his father had severe gout. On examination, the left first metatarsophalangeal joint was swollen and tense, but all the other joints were unremarkable. Rotation of the lumbar spine was restricted. What test would be most useful in establishing the diagnosis?