Archives: MRCP Part 2

MRCP2-2507

A 65-year-old female presents with a 6-month history of increasing lethargy and malaise. She has no past medical history and travels widely, last visiting the Middle East two weeks prior to this admission, returning with a respiratory tract infection that appears to be resolving. She is a lifelong non-smoker and does not drink alcohol to excess. Over the past four weeks, she reports increasing bilateral persistent headache associated with binocular visual blurring. In addition, she describes a non-specific abdominal discomfort without any changes in bowel habit.

On examination, you note bilateral axillary lymphadenopathy and conjunctival pallor. Cardiovascular and respiratory system examinations were unremarkable. Neurological examination is unremarkable. Fundoscopy reveals dilated tortuous retinal veins. Abdominal examination reveals hepatosplenomegaly. Lastly, you note areas of purpura around her left anterior shin and her right upper arm. A chest radiograph is unremarkable.

Her blood results are as follows:

Hb 87 g/l
MCV 79 fl
Platelets 190 * 109/l
WBC 3.4 * 109/l
Na+ 142 mmol/l
K+ 4.5 mmol/l
Urea 7.6 mmol/l
Creatinine 89 µmol/l
Adj Calcium 2.47 mmol/l
Phosphate 1.34 mmol/l
LDH 1890 (normal range 140-280 units/L)
Serum electrophoresis IgM paraprotein band at 5.4 g/L

A bone marrow biopsy demonstrates 14% infiltration of lymphoplasmacytic cells

What is the most likely diagnosis?

MRCP2-2508

A 70-year-old woman presents to the emergency department with a headache and monocular visual loss. She has a history of type 2 diabetes and takes metformin. On examination, her left eye has significantly impaired vision, and fundoscopy reveals sausage-like dilation of the retinal veins and centrally located retinal haemorrhages with macular oedema. Her blood tests show elevated ESR and IgM levels. What is the probable diagnosis?

MRCP2-2509

An 81-year-old man presents to the clinic with a 6-month history of excessive night sweats and a significant weight loss of 10 kg. His vital signs are stable. Upon examination, he has enlarged cervical and inguinal lymph nodes on both sides.

The following are his blood test results:

– Hemoglobin (Hb): 115 g/L (normal range for males: 135-180; females: 115-160)
– Platelets: 185 * 109/L (normal range: 150-400)
– White blood cells (WBC): 7.2 * 109/L (normal range: 4.0-11.0)
– Sodium (Na+): 135 mmol/L (normal range: 135-145)
– Potassium (K+): 4.4 mmol/L (normal range: 3.5-5.0)
– Urea: 6.2 mmol/L (normal range: 2.0-7.0)
– Creatinine: 85 µmol/L (normal range: 55-120)
– C-reactive protein (CRP): 4 mg/L (normal range: <5) Immunoglobulin levels: – IgG: 2.4 g/L (normal range: 6-16)
– IgM: 32 g/L (normal range: 0.4-2.5)
– IgA: 0.2 g/L (normal range: 0.8-3.0)

Immunofixation shows Kappa restriction.

What is the most probable diagnosis?

MRCP2-2510

A 65-year-old woman with a metallic mitral valve replacement and atrial fibrillation (AF) is scheduled for extensive abdominal surgery. What is the best course of action for her anticoagulation therapy?

MRCP2-2511

A 25-year-old woman presents with a history of easy bruising. She is currently undergoing investigations for menorrhagia under the care of the gynaecology team. The patient is not taking any regular medications. Her father had prolonged bleeding after a dental procedure.

Laboratory results reveal:

– Hemoglobin (Hb): 110 g/L
– Mean corpuscular volume (MCV): 74 fL
– White blood cells (WBC): 4.2 x 10^9/L
– Platelets: 135 x 10^9/L
– Activated partial thromboplastin time (APTT): 45 seconds
– International normalized ratio (INR): 1.0

What is the most probable diagnosis?

MRCP2-2512

A 67-year-old male patient complains of blurred vision and anemia, with a hemoglobin level of 89 g/L. A total protein test reveals an elevated globulin fraction. Further testing shows an IgM paraprotein level of 37 g/L, and a bone marrow aspirate reveals a lymphoplasmacytic infiltrate. What would be the most crucial investigation to conduct next?

MRCP2-2513

A 49-year-old female with colorectal cancer (Duke’s C) on chemotherapy presents with an acutely painful swollen left leg. She reports that the swelling has been increasing for the past twelve hours and she can see new veins on her calf that were not there before. She has a history of deep vein thrombosis (DVT) and feels that this is similar.

Upon examination, her left leg is 4 cm larger than the right. The medical team starts her on rivaroxaban for a suspected DVT and orders an ultrasound Doppler of the leg.

What is her Well’s score?

MRCP2-2514

A 35-year-old woman presented to the clinic for evaluation. She had been diagnosed with HIV 3 weeks ago and was scheduled to start antiretroviral therapy during this visit. She reported feeling fatigued and experiencing severe headaches. She had no significant medical history.
During the examination, she had a low-grade fever of 37.8°C and some purplish lesions on her lower limbs. The rest of the examination was unremarkable.
Lab Results:
Hemoglobin (Hb) 100 g/l 120 – 160 g/l
White blood cell count (WBC) 4.8 × 109/l 4.0 – 11.0 × 109/l
Neutrophils 2.5 × 109/l 1.5 – 7.0 × 109/l
Platelets (PLT) 10 × 109/l 150 – 400 × 109/l
What is the most crucial test to perform next?

MRCP2-2515

A 65-year-old man who works at a local hardware store is admitted to the Emergency Department with a severe headache and weakness affecting the right-hand side of his body. He has been feeling unwell for the past few days with headaches, loss of appetite, and diarrhea. Apparently, he has eaten the same food as a number of coworkers at the store who have fallen ill with diarrhea – two of whom are in the local hospital with kidney disease.

On examination, his blood pressure is 160/95 mmHg; pulse is 80/min and regular. There is evidence of a purpuric rash and petechial hemorrhages. Abdomen is soft and generally tender, and he has active bowel sounds. You confirm right upper motor neuron 7th nerve palsy.

Investigations:
s
Haemoglobin (Hb) 110 g/l (schistocytes on blood film) 135 – 175 g/l
White cell count (WCC) 11.5 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 40 × 109/l 150 – 400 × 109/l
Sodium (Na+) 138 mmol/l 135 – 145 mmol/l
Potassium (K+) 5.0 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 150 µmol/l 50 – 120 µmol/l
Lactate dehydrogenase (LDH) 900 u/l 140 – 280 u/l
Urine Blood ++ protein ++

What is the most appropriate course of action?

MRCP2-2516

A 28-year-old patient who is 10 weeks pregnant presents at the antenatal booking clinic. She reports feeling fatigued and having a poor appetite. She has no significant medical history.

During the examination, she appears comfortable at rest but looks pale. Her chest is clear, heart sounds I&II are present, and her abdomen is soft and non-tender. She has bilateral ankle oedema. Her blood pressure is 110/75 mmHg, and her heart rate is 80/min.

The following investigations were conducted in the clinic:

Hb 94 g/l
MCV 69 fl
Platelets 168 * 109/l
WBC 9.1 * 109/l
Hb electrophoresis positive HbA2
Rhesus negative
Blood Group AB

Na+ 139 mmol/l
K+ 3.9 mmol/l
Urea 7.6 mmol/l
Creatinine 99 µmol/l

What is the most probable underlying condition?