Archives: MRCP Part 2

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.

MRCP2-4565

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?

MRCP2-4566

You are asked to see a 35-year-old man with a three year history of recurrent episodes of asymmetrical joint pains involving his knees, ankles and elbows. Two to four joints tend to be affected at any one time and each joint may be affected from two to four weeks each time.

In the last decade he has also had recurrent painful mouth sores. On this occasion, he also complains of a severe occipital headache, mild abdominal pain and some discomfort on passing urine.

On examination, his temperature is 38°C. His left knee and right ankle joints are painful, swollen and tender. Superficial thrombophlebitis is noted in the right leg.

Investigations show:

Hb 99 g/L (130-180)

WCC 11.6 ×109/L (4-11)

Platelets 420 ×109/L (150-400)

ESR 60 mm/hr (0-15)

Plasma sodium 138 mmol/L (137-144)

Plasma potassium 4.3 mmol/L (3.5-4.9)

Plasma urea 6.9 mmol/L (2.5-7.5)

Plasma creatinine 95 µmol/L (60-110)

Plasma glucose 5.8 mmol/L (3.0-6.0)

What is the most likely diagnosis?

MRCP2-4567

A 27-year-old Japanese city banker with a history of irritable bowel disease presents with recurrent mouth ulcers that have been occurring more frequently despite previous treatment with chlorhexidine mouthwashes, oral aciclovir, and prednisolone lozenges. He has also been experiencing pain at the tip of his penis during sexual intercourse and has been feeling increasingly tired, leading him to give up playing football. He denies any weight loss and his appetite is unchanged. On examination, multiple aphthous ulcers are found in the oral cavity, as well as a small aphthous ulcer on the tip of the penis. Abdominal examination reveals mild, diffuse tenderness but no masses, and rectal examination reveals no abnormality. Investigations reveal a low haemoglobin level, elevated white cell count and platelets, and slightly elevated urea and creatinine levels. The erythrocyte sedimentation rate is slightly elevated, but anti-nuclear antibody and anti-dsDNA antibody tests are negative. The patient is currently taking oxytetracycline for acne. What is the most likely diagnosis?

MRCP2-4568

A 30-year-old man presents to his GP with severe pain in his mouth and groin that has been ongoing for 8 weeks. He has previously visited his GP multiple times for fatigue and general malaise, which were attributed to viral illnesses. He was diagnosed with non-specific colitis of unknown origin 8 months ago, which resolved on its own. He also had a single DVT in his left leg 6 years ago, which was treated with oral anticoagulants. He smokes 20 cigarettes a day and drinks 20 units of alcohol per week. He is not taking any regular medication. He denies having joint pain or swelling, and he is not aware of any family history as he was adopted at birth.

During the examination, he appeared pale, and his heart rate was 88, and his blood pressure was 118/78 mmHg. His cardiovascular system was normal, and his abdomen was unremarkable. Multiple aphthous ulcers were found in his oral mucosa, and multiple shallow ulcers were found in his groin area. His joints were normal.

Initial investigations showed the following results:

Hb 139 g/l
Platelets 333 * 109/l
WBC 5.1 * 109/l
ESR 22 mm/hr
CRP 28 mg/l
Rheumatoid factor negative
Anti CCP negative
ANA negative
HLA B27 positive

What is the most likely underlying diagnosis?

MRCP2-4569

A 35-year-old woman visits the Rheumatology Clinic for evaluation. She reports experiencing pain in multiple joints, particularly in her back, wrists, ankles, and feet, with noticeable involvement of the distal interphalangeal joints. During the examination, psoriatic patches are observed on her elbows, and her nails show onycholysis, transverse ridging, and pitting. There is also swelling, pain, and limited movement in her DIP. Despite being prescribed methotrexate, there is no improvement in her condition. You decide to treat her with adalimumab. What is the mechanism of action of adalimumab?

MRCP2-4570

A 65-year-old Caucasian man complains of worsening hearing loss and difficulty with chewing. He reports a family history of similar symptoms that required medication in his father and paternal uncles. Upon examination, frontal bossing is observed. Laboratory tests reveal an elevated alkaline phosphatase and a serum calcium level at the upper limit of normal. All other investigations are unremarkable. What is the initial treatment option for this patient?

MRCP2-4571

A 45-year-old man presents with a swollen and painful right knee, along with difficulty in walking for the past three days. Upon examination, the knee appears red, warm, tender, and has limited movement. The knee aspirate shows no organisms on Gram stain, but plenty of leucocytes and weakly positively birefringent crystals on polarised light microscopy. A knee radiograph reveals linear meniscal calcification. Recent blood tests show elevated WBC count, neutrophils, and ESR, along with corrected calcium and phosphate levels outside the normal range. Alkaline phosphatase and urea, electrolytes, and creatinine levels are normal. What is the underlying cause of acute monoarthritis in this patient?

MRCP2-4572

A 45-year-old man with poorly controlled diabetes and a history of social alcohol consumption presents with an acutely swollen and red mid foot that has been bothering him for the past three weeks. He denies any recent foot injuries. Upon examination, the mid foot is warm and pedal pulses are intact. However, there is a glove and stocking distribution of sensory loss bilaterally. Recent blood tests reveal normal FBC, CRP, and UEC, and a foot radiograph appears normal. What should be the next step in managing this patient?

MRCP2-4573

Ms. Johnson is a 65-year-old woman with pulmonary fibrosis secondary to dermatomyositis. She visits your clinic after seven weeks of being on high dose steroids due to disease progression. During the consultation, Ms. Johnson reports an increase in shortness of breath, especially when she exerts herself. She denies any fever or weight loss but has a chronic cough that produces white sputum, which has remained stable.

Upon examination, Ms. Johnson appears comfortable at rest, and her chest auscultation is surprisingly clear. Her oxygen saturation is 97% at rest, but after walking to the end of the corridor and back, it drops to 82%. An urgent chest radiograph is ordered, which reveals bilateral patchy infiltrates.

What is the most appropriate course of action for management?