Archives: MRCP Part 2

MRCP2-4599

A 68-year-old woman presents to her GP with a 2-week history of progressive shoulder pain. She reports difficulty getting dressed in the morning due to the pain. She also feels weak and fatigued and has lost around 2 kg in weight. There is no significant medical history. On examination, she has a temperature of 37.8 °C, heart rate of 90 bpm, and blood pressure of 127/77 mmHg. Heart sounds are normal, and breath sounds are vesicular bilaterally. Abdomen is soft and non-tender with no palpable organomegaly. Bilateral proximal muscle stiffness is noted. What is the most likely diagnosis?

MRCP2-4600

A 50-year-old woman with insulin-dependent diabetes complains of increasing lower back pain over the past two days. The pain is severe, causing her to lose sleep at night. Upon examination, her temperature is 37.8°C, pulse is 105/min, and blood pressure is 110/70 mmHg. The heart, lungs, and abdomen appear normal, but she experiences tenderness on the T12 vertebra. Blood tests reveal a low Hb level of 108 g/L (normal range: 115-165), high WBC count of 19.9 ×109/L (normal range: 4-11), 94% neutrophils (normal range: 40-75), high platelet count of 380 ×109/L (normal range: 150-400), high ESR of 90 mm/hr (normal range: 0-20), and high CRP of 200 mg/L (normal range: <10). A chest x-ray, thoracic spine x-ray, and urine dipstick test all appear normal. What is the diagnosis?

MRCP2-4578

A 67-year-old male presents to the emergency department with a 4-day history of haemoptysis, fever, and joint pains. He has a medical history of hypertension and chronic sinusitis, and takes amlodipine. He smokes 10 cigarettes daily and drinks wine 1-2x/week. He recently returned from a trip to Goa.

On examination, his heart rate is 101 beats per minute, blood pressure is 167/94 mmHg, oxygen saturations are 94%, respiratory rate is 21/minute, and temperature is 37.9ºC. Chest auscultation reveals scattered crackles and decreased air entry at the right base. There is mild tenderness and swelling at the wrists bilaterally. Abdominal examination is normal, and there is no peripheral oedema.

Urinalysis shows protein +++ and blood +++ but is negative for leucocytes, nitrites, and glucose. Blood tests reveal a low Hb level, elevated creatinine, and a high CRP level. A chest x-ray shows patchy airspace opacification in the lung fields bilaterally.

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?

MRCP2-4580

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?

MRCP2-4581

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:

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?

MRCP2-4585

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?

MRCP2-4586

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?

MRCP2-4587

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?