Archives: MRCP Part 2

MRCP2-2496

A 35-year-old man presents with breathlessness on exertion of 3 months’ duration. He is usually fit and relatively athletic and now needs to stop for breath on climbing a single flight of stairs.

His general practitioner has arranged investigations for possible renal stones, and he completed a 6-month course of warfarin for deep vein thrombosis (DVT) in the last year, but otherwise, he has no significant previous medical history.

Examination shows pale conjunctivae and a pulse of 100 bpm; heart sounds are normal, and the jugular venous pressure is not raised.

Investigations reveal the following:

Haemoglobin (Hb) 63 g/l 135–175 g/l

White cell count (WCC) 2.5 × 109/l 4.0–11.0 × 109/l

Neutrophils 1.1 × 109/l 2.5–7.58 × 109/l

Platelet (PLT) 75 × 109/l 150–400 × 109/l

Mean corpuscular volume (MCV) 80 fl 80–100 fl

Reticulocytes 90 × 109/l 25–85× 109/l

Blood film Marked anisocytosis, with polychromasia and hypochromatic cells

Ferritin 10 μg/l 20–250 µg/l

Urine dipstick Blood+++

Mid-stream urinalysis No cells

Urine culture Negative

What is the most likely diagnosis?

MRCP2-2497

A 75-year-old man presents with worsening headaches, three TIAs in the past 6 months and exertional angina. He is a smoker of 30 cigarettes per day and has a history of hypertension for which he takes ramipril 10 mg daily.

On examination, his BP is 165/90 mmHg and he looks plethoric.

Investigations:

Investigation Result Normal values

Haemoglobin (Hb) 185 g/l 135 – 175 g/l

White cell count (WCC) 14.1 × 109/l 4.0 – 11.0 × 109/l

Platelets (PLT) 520 × 109/l 150 – 400 × 109/l

Potassium (K+) 5.4 mmol/l 3.5 – 5.0 mmol/l

Creatinine (Cr) 160 μmol/l 50 – 120 µmol/l

Which of the following results of further investigations is most likely to differentiate between primary and secondary polycythaemia?

MRCP2-2498

A 56-year-old alcoholic man with chronic hepatitis C presents to the emergency department with blisters and crusted lesions on his face and lower arms. Laboratory tests reveal elevated plasma porphyrins and elevated uroporphyrin I in the urine, and isocoproporphyrin in the faeces. Skin biopsy shows subepidermal blisters with minimal inflammation, marked solar elastosis, thickening of the vessel wall in the papillary dermis and ‘caterpillar bodies’ in the roof of the blister. What is the most likely diagnosis?

MRCP2-2499

A patient in his mid-50s has been admitted with deep vein thrombosis in his left lower limb. The diagnosis was made by the FY1 who promptly started him on warfarin. However, two days later, you are called to assess the patient as he has developed skin necrosis on his right thigh.

What could be the probable reason for the skin necrosis?

MRCP2-2500

A 25 year old male of Nigerian descent presents to the ED with acute shortness of breath, fever, and dry cough. He reports that he can only tolerate exercise for about 10 yards due to his shortness of breath and is experiencing severe right-sided chest pain. The patient has a history of sickle cell anemia but has not been hospitalized in the past 2 years.

Vital signs:
– Heart rate: 94 bpm regular
– Blood pressure: 112/74 mmHg
– Temperature: 38.3°C
– Respiratory rate: 22 breaths per minute
– Urine output: under 30 ml/hr
– Oxygen saturations: 93% on room air

Physical examination reveals shallow breathing, bronchial breath sounds, and crepitations to the right base of the respiratory system.

Lab results:
– Hemoglobin: 7.7 g/dL
– Platelets: 200 * 10^9/L
– White blood cells: 13.2 * 10^9/L
– Bilirubin: 36 µmol/L
– Urea: 8.2 mmol/L
– Creatinine: 146 µmol/L

What is the most crucial initial step in managing this patient’s condition?

MRCP2-2469

A 67-year-old woman presents at the outpatient clinic for a follow-up on her chronic lymphocytic leukemia (CLL) diagnosis, which she has had for six months. She reports having three chest infections in the past year but is otherwise in good health. Her test results show a white cell count of 30.2 ×109/L (4-11), lymphocytes of 26.2 ×109/L (1.5-4), and a serum electrophoresis that indicates low levels of IgA and IgM. Her hemoglobin and platelet count are within normal ranges. What is the most appropriate management option for this patient?

MRCP2-2470

A 65-year-old woman presents to the Emergency Department with persistent and heavy nosebleeds from both nostrils. The ENT Registrar successfully packs the nose, but the patient complains of continuous post-nasal drip and has had several episodes of black, tarry stools. She has been experiencing joint pain in her knees and hands for several months.
There is no significant medical history, except for a routine gallbladder removal surgery a year ago. Family history is unremarkable, and she is not taking any medications.
Upon examination, she has moderate synovitis in several proximal interphalangeal, metacarpophalangeal, and large joints. Her blood pressure is 95/60 mmHg, heart rate 110 bpm, and respiratory rate 22 breaths per minute. Her skin is cool to the touch, and she has multiple bruises.
Lab results:
– Hemoglobin (Hb): 80 g/l (normal range: 120-160 g/l)
– White cell count (WCC): 4.5 × 109/l (normal range: 4.0–11.0 × 109/l)
– Platelets (PLT): 600 × 109/l (normal range: 150–400 × 109/l)
– Erythrocyte sedimentation rate (ESR): 70 mm/hour (normal range: 0-20 mm/hour)
– Partial thromboplastin time (PTT): 80 seconds (normal range: 23.0–35.0 seconds)
– Prothrombin Test (PT): 13 seconds (normal range: 10.6–14.9 seconds)
– Factor VIII activity: Reduced
What is the most appropriate treatment for this patient’s bleeding?

MRCP2-2471

A 35-year-old man is admitted to the Cardiology Ward from the Primary Care Clinic. He has a history of ulcerative colitis which is usually quiescent. However, despite maximal mesalazine and prednisolone 60 mg daily, he is opening her bowels 8–10 times per day with bloody diarrhoea.
On the ward, his blood pressure is 120/80 mmHg and his heart rate is 88 bpm. His temperature is 37.5 °C.

On examination, his abdomen is distended and tender, with sparse bowel sounds. His right leg is also swollen.

Investigations:
Haemoglobin (Hb) 140 g/l 130–170 g/l
White cell count (WCC) 8.5 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 200 × 109/l 150–400 × 109/l
C-reactive protein (CRP) 10 mg/l < 10 mg/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 80 µmol/l 50–120 µmol/l
Chest X-ray (CXR) Normal
Abdominal X-ray (AXR) Dilated left-sided colon with evidence of mucosal oedema
Right leg venogram Above-knee deep venous thrombosis

What is the most appropriate way to manage his deep vein thrombosis?

MRCP2-2472

A 35-year-old man presents with persistent heartburn for the past six weeks. He has no known medical conditions and is not taking any medications. Upon examination, there are no notable findings. A gastro-oesophageal endoscopy is performed, revealing gastritis. Biopsies of the stomach confirm the presence of a low-grade mucosa-associated lymphoid tissue lymphoma (maltoma/marginal zone lymphoma) with Helicobacter pylori present. A CT scan of the chest, abdomen, and pelvis shows no signs of additional disease, and a bone marrow biopsy is normal. The thickness of the stomach wall is not clearly visible. What treatment plan would you suggest?

MRCP2-2473

A 38-year-old male presents with dyspepsia and an irregular area is found during gastroscopy. An antral biopsy reveals mucosal associated lymphoid tissue lymphoma (MALT lymphoma). He has no other sites of disease and is in good health. What is the recommended first line treatment for this patient?