Archives: MRCP Part 2

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?

MRCP2-4584

A 36-year-old woman presents to rheumatology clinic with a 2-month history of symmetrical swelling of the ankles and fingers. She also complains of joint pain and stiffness. The stiffness is primarily worse in the early morning and eases with use. Apart from a recent sore throat, she is otherwise well.

She has a family history of type 1 diabetes mellitus. She does not take any prescribed medication but has found herself relying on over-the-counter analgesics to get through the day.

On examination, she has bilateral swelling of the index, ring and middle fingers and bilateral ankle swelling. She has a full range of movement in the fingers, wrists and ankles. There is marked swelling and tenderness to palpation at the distal interphalangeal joints in the index, middle and ring fingers on both sides. There are no skin changes, but yellowing and pitting of the nails are noted.

Blood tests show:

Hb 11.1 g/dl
Platelets 305 * 109/l
WBC 7.8 * 109/l

Na+ 141 mmol/l
K+ 4.2 mmol/l
Urea 5.8 mmol/l
Creatinine 64 µmol/l

Bilirubin 13 µmol/l
ALP 83 u/l
ALT 15 u/l
ESR 50 mm/hr
CRP 39 mg/L
Rheumatoid factor negative

Hand X-ray shows mild erosion at the distal interphalangeal joints of the index, middle and ring fingers on both hands.

What is the diagnosis?

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?

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?

MRCP2-4561

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?

MRCP2-4562

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?

MRCP2-4563

A 42-year-old woman visits her GP with concerns about a scaly patch of skin on her nose. Upon examination, the doctor observes a shiny-bordered, pearly nodule measuring approximately 0.3 cm x 0.3 cm.

The patient has a history of inflammatory bowel disease and is currently taking Azathioprine, but continues to smoke despite advice from her gastroenterologist.

What identifiable risk factor in her medical history is associated with her current presentation?

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.