Archives: MRCP Part 2

MRCP2-4596

A 65-year-old woman presents with a one-week history of fever, chills, nausea, vomiting, and joint pain. Her GP prescribed a five-day course of amoxicillin with no improvement. She has osteoarthritis and complains of severe use-related pain in her distal interphalangeal joints and knees, with no previous swelling. She denies cough, sore throat, or dysuria. Her medical history includes diabetes mellitus, hypertension, coronary artery disease, and gout. On examination, she is acutely unwell, with a temperature of 39.8°C, pulse of 96 beats/min, and BP of 190/100 mmHg. Investigations show mild cardiomegaly on chest x-ray, and blood cultures and urinalysis are negative. Which investigation should be performed next?

MRCP2-4590

An 89-year-old male is admitted to hospital after recurrent mechanical falls. His past medical history includes an anterior resection for sigmoid carcinoma, type 2 diabetes mellitus and gout.

Three days into his admission, he was treated for hospital-acquired pneumonia with three days of intravenous tazocin. One week into his admission, he developed a swollen inflamed 2nd MTP joint and colchicine was started.

After becoming medically stable 10 days into admission and awaiting a package of care at home, nursing staff report diarrhoea, with type 7 stool up to 7 times a day. He has no laxatives prescribed. One set of stool cultures were sent within 15 minutes of the last episode, which have proved negative for Clostridium difficile toxin and, MC+S and norovirus.

What is the most likely cause of his diarrhoea?

MRCP2-4580

A 27-year-old woman presents with a rash on her face, neck, and trunk. The rash is ill-defined, polycyclic, erythematous, and some areas are papular with scaling. Some of the rash has healed without scarring. Exposure to sunlight exacerbates the rash. She has no other significant medical history.

Her blood tests show a hemoglobin level of 111 g/L (normal range: 115-165), a white blood cell count of 8.9 ×109/L (normal range: 4-11), neutrophils at 89% (normal range: 40-75), and a platelet count of 166 ×109/L (normal range: 150-400). Her ESR is 16 mm/hr (normal range: 0-20) and CRP is 3 mg/L (normal range: <10). Urea, electrolytes, and creatinine are normal. She tests positive for anti-nuclear antibody at a titer of 1:320, negative for anti-dsDNA antibody, positive for anti-Ro antibody, and negative for anti-La antibody. What is the likely diagnosis?

MRCP2-4588

A 67-year-old woman presents to the Rheumatology Clinic for evaluation. She has been experiencing progressive back pain for the past 3 years and now reports a burning pain that radiates down from her buttocks into both legs when she walks only a short distance, causing her to have to sit and rest until the pain subsides. She smokes 6 cigarettes per day and has a history of osteoarthritis and hypertension. On examination, her blood pressure is 140/90 mmHg; pulse is 75/min and regular. Her ABPI is 0.98. Lumbar spine movement is limited by pain and stiffness. Straight leg raise is normal.
Investigations:
Hb 129 g/l
WCC 6.8 x109/l
PLT 179 x109/l
Na+ 138 mmol/l
K+ 4.2 mmol/l
Creatinine 98 micromol/l
ESR 12 mm/1st hour
Lumbar spine x-ray shows evidence of bilateral facet joint arthritis and disc space narrowing.
What is the most likely diagnosis?

MRCP2-4579

A 55-year-old man presented with a four week history of general malaise and a three day history of a left foot drop, a right ulnar nerve palsy and a widespread purpuric rash.

He reported arthralgia but had no clinical evidence of inflammatory joint disease. Upon investigation, his ESR was found to be 100 mm/hr (0-20) and both ANCA and ANA were negative. However, his rheumatoid factor was strongly positive and his C3 and C4 levels were low.

Additionally, his urine dipstick showed blood ++ and no protein. Despite a normal echocardiogram and negative blood cultures, what is the most likely diagnosis for this patient?

MRCP2-4587

A 35-year-old man complains of occasional joint pains affecting his elbows, hips and ankles for the past four months. He describes each episode as involving pain, swelling and redness in one of the mentioned joints, which usually resolves with anti-inflammatory medication within a day or two.
Lately, the frequency of attacks has increased to once or twice a week from the previous one or two attacks every month. The most recent episode, involving the left knee, occurred two days ago.
During the examination at the clinic, there were no signs of synovitis in any of the joints.
What is the most appropriate initial step to take?

MRCP2-4583

A 54-year-old man presents with a scaly rash on the back of his hands. The erythematous rash is located on the extensor aspects of his fingers, particularly over the MCP and PIP joints. He has also noticed a violaceous swelling of his left upper eyelid. These symptoms have been bothering him for the past two weeks, and he has tried using an emollient cream without any improvement. His two brothers both have psoriasis, and he has been healthy apart from childhood eczema.

In addition to the rashes, he has a palpable mass in the left iliac fossa that is non-tender, and a nodular liver edge can be felt in the right upper quadrant. His conjunctiva are pale. He reports experiencing varying bowel movements, ranging from diarrhea to occasional constipation. He tried taking mebeverine but did not find any relief. There are no other rashes present.

What is the probable cause of this rash?

MRCP2-4586

A 50-year-old man with RA is currently on s.c. adalimumab (40 mg/2week), methotrexate 15 mg/week, folic acid 5 mg/day, and prednisolone 5 mg/day. He presents to the MAU with a painful swollen right ankle and is unable to weight bear on the right leg. There are no drug allergies. On examination, his temperature is 38.8℃, BP is 90/60 mm Hg, and pulse is 110/min. The right ankle is warm, tender, and there is a tense joint effusion. Bloods including blood cultures have been collected, and fluid resuscitation has been initiated. What is the most appropriate step in his management?

MRCP2-4585

A 72-year-old male was admitted to the medical ward for the treatment of a CURB = 4 community-acquired pneumonia. He is now awaiting discharge but since his illness, he has not returned to his pre-morbid state. His past medical history includes two previous myocardial infarctions, hypertension, type 2 diabetes mellitus, duodenal ulcer and obesity.

In addition, the physiotherapists report significant left knee pain to be contributing to poor mobility. On questioning, the patient reports that the pain is chronic and has been progressively worsening for about 3 years. His GP had sent him for two X-rays previously that demonstrated cartilage loss and osteophyte formation, with a reduction in joint space.

On examination, you note significant crepitus in the left knee, with reduced range of movements in flexion and extension. You also note bony outgrowths in the proximal interphalangeal joints of his second and third digits of his left hand. He had successfully lost 7kg in weight and had previously taken 1g paracetamol four times a day regularly but neither measure seemed to help his pain.

What is the most appropriate next step?

MRCP2-4581

A 28-year-old female diagnosed with Granulomatosis with polyangiitis, which involves glomerulonephritis and pulmonary complications, undergoes six months of monthly pulsed i.v. cyclophosphamide treatment. Despite the treatment, her disease remains active, and she is prescribed oral cyclophosphamide (100 mg/day for six months) followed by azathioprine. What is her highest risk factor?

Risk Factor: