Archives: MRCP Part 2

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?

MRCP2-4587

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?

MRCP2-4585

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?

MRCP2-4577

A 45-year-old construction worker presents with a six-month history of pain and swelling in both hands, which is most severe in the mornings. He takes diclofenac tablets for pain relief. The patient’s job involves the use of vibrating tools. On examination, the metacarpophalangeal joints and wrists of both hands are warm, swollen, and tender. Investigations reveal a low Hb level, elevated ESR, and periarticular decalcification on x-ray. What is the most probable diagnosis?

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?

MRCP2-4564

A 65 year old woman presented to her General Practitioner with complaints of bilateral shoulder and hip girdle pain and stiffness lasting up to two hours each morning for the past three months. Despite taking simple analgesics, her symptoms were limiting her daily activities. She denied experiencing headaches, visual disturbances, or jaw claudication, but reported intermittent episodes of dry mouth and dry eyes for several years. Her medical history included well-controlled coeliac disease on a gluten-free diet. On examination, mild muscular tenderness was noted across the shoulder and hip girdles, but no other inflamed or tender joints were found. Blood tests revealed an elevated ESR of 65, leading to a diagnosis of PMR and a prescription of 20 mg prednisolone daily. However, after six weeks, her symptoms had not significantly improved, and she was referred to rheumatology clinic. Further investigations, including X-rays of her hands, were conducted, and the results are listed below. What is the correct diagnosis?

Haemoglobin 110 g / dL
White cell count 8.9 * 109/l
Neutrophils 7.8 * 109/l
Platelets 456 * 109/l
Urea 6.2 mmol / L
Creatinine 87 micromol / L
Sodium 138 mmol / L
Potassium 4.1 mmol / L
Ferritin 180 ng / mL
Erythrocyte sedimentation rate 75 mm / h
Rheumatoid factor Negative
Connective tissue ANA Negative
Anti-CCP antibodies 58 EU (reference < 20)
Creatinine kinase 89 U / L (reference 5-130)

X-ray hands: minor degenerative change in multiple interphalangeal joints of both hands; no evidence of erosive arthropathy.

MRCP2-4562

A 57-year-old man presents to the emergency department with a 2-week history of increasing fatigue and shortness of breath with exertion. He denies any recent infections or fainting episodes. The patient has a medical history of Crohn’s disease, type 2 diabetes, epilepsy, and gout. He was recently started on azathioprine.

During the examination, the patient appears pale. Heart and lung sounds are normal, and the abdomen is soft and non-tender.

Laboratory results show:

– Hb 81 g/L (135 – 180)
– Platelets 66 * 109/L (150 – 400)
– WBC 1.1 * 109/L (4.0 – 11.0)
– Neuts 0.3 * 109/L (2.0 – 7.0)
– Na+ 136 mmol/L (135 – 145)
– K+ 4.1 mmol/L (3.5 – 5.0)
– Urea 3.1 mmol/L (2.0 – 7.0)
– Creatinine 83 µmol/L (55 – 120)

What medication should be discontinued based on this patient’s presentation?

MRCP2-4561

A 50-year-old woman comes to the Rheumatology Clinic for evaluation. She has been experiencing weight loss, night sweats, and multiple joint pains. Additionally, she has noticed significant hair loss with scarring around the affected areas. She is also sensitive to the sun, particularly on her face, and requires factor 50 sunscreen. On examination, her blood pressure is 155/82 mmHg, and she has a flushed facial appearance. She has small joint polyarthropathy, particularly affecting her fingers, toes, ankles, and wrists. Her BMI is 21 kg/m2, and there is scarring alopecia on her scalp. Her laboratory results show a low hemoglobin level, elevated ESR, and positive urine for blood and protein. Which test is most likely to be positive?

MRCP2-4565

A 38-year-old Turkish man presents with superficial thrombophlebitis in his leg veins.

Upon questioning, he reports experiencing recurrent episodes of oral and genital ulcers over the past year, some of which have resulted in scarring. He also has a history of anterior uveitis.

Recent blood tests indicate a normocytic normochromic anemia, normal liver function tests, urea and electrolytes, and an elevated erythrocyte sedimentation rate (66 mm/hr). A venous Doppler revealed below knee deep venous thrombosis.

Which medication should he be started on?