Archives: MRCP Part 2

MRCP2-2484

A 25-year-old woman presents with sudden-onset dysarthria and right-sided weakness. You see her 10 h after the event and her symptoms have now resolved. She takes the birth control pill. She is employed full-time and smokes 5–10 cigarettes daily. Alcohol intake is minimal. She lives with her partner. Family history is unremarkable other than a possible deep vein thrombosis in her grandfather.
The examination is unremarkable, other than a lacy rash over her thighs and a grade II ejection systolic murmur. Computed tomography of the brain performed 2 h after admission is unremarkable.
Investigations reveal the following:

Haemoglobin (Hb) 120 g/l 115–155 g/l
White cell count (WCC) 4.0 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 140 × 109/l 150–400 × 109/l
Partial thromboplastin time (PTT) 42 s 23.0–35.0 s
What is the most likely identity of the rash?

MRCP2-2485

A 28-year-old man who is HIV positive has been on anti-retroviral therapy for the past 2 years and has been doing well. However, he has recently developed abdominal distension and discomfort in the right iliac fossa. Upon examination, a mass is palpable in the right lower quadrant. A biopsy reveals a B cell lymphoma with sheets of medium-sized lymphoid cells exhibiting high proliferative activity and a starry sky appearance. What is the most probable cytogenetic abnormality that will be detected?

MRCP2-2451

A 35-year-old man presents with a 48 hour history of swelling in his right leg. He recently returned from a trip to Asia. He has no significant medical history, does not smoke, and is not taking any medications. Physical examination is normal except for the swollen leg. An ultrasound confirms a deep vein thrombosis below the knee, and he is started on enoxaparin 1.5 mg/kg daily subcutaneously and 10 mg of warfarin. On the third day after starting warfarin, he develops dark spots on his thighs. His platelet count remains stable at 210 × 109/l. What is the most likely cause of the dark spots on his thighs?

MRCP2-2452

A 55-year-old man is diagnosed with a deep vein thrombosis after being hospitalized for a fracture in his left femur due to a car accident.

What is the accuracy of thrombophilia testing?

MRCP2-2453

A 65-year-old woman arrives at the Emergency Department at 1 am with sudden onset headache, weakness in her left upper and lower limbs, nausea, vomiting, and lethargy. The CT scan of her head reveals no abnormalities, but her blood tests show a hemoglobin level of 60 g/L, a platelet count of 5 × 109/L, and mild kidney damage. The blood film examination confirms genuine thrombocytopenia and extensive red cell fragments. What is the immediate action that should be taken?

MRCP2-2454

A 32-year-old woman is admitted to the gynecology ward at 24 weeks gestation in her first pregnancy. She had seen her midwife and complained of feeling generally unwell. Her husband reported that she has become very vague and disoriented. The midwife found her blood pressure to be 140/89 mmHg, which was higher than her booking blood pressure of 120/80 mmHg.

On admission, her blood tests showed a hemoglobin level of 79 g/L (115-165), a white cell count of 11 ×109/L (4-11) with a normal differential, and a platelet count of 30 ×109/L (150-400). Her MCV was 103 fL (80-96), and her reticulocyte count was 12.5%. The blood film showed red cell fragmentation with thrombocytopenia and platelet anisocytosis, as well as polychromasia. Her serum lactate dehydrogenase was 1112 U/L (10-250), serum sodium was 140 mmol/L (137-144), serum potassium was 3.7 mmol/L (3.5-4.9), serum urea was 15.2 mmol/L (2.5-7.5), serum creatinine was 200 µmol/L (60-110), serum total bilirubin was 73 µmol/L (1-22), serum alanine aminotransferase was 40 U/L (5-35), and serum alkaline phosphatase was 160 U/L (45-105). Her coagulation screen was normal, but her fibrinogen level was elevated at 5.3 g/L (1.8-5.4).

What treatment would you recommend for this patient to the obstetric team?

MRCP2-2455

A 29-year-old woman presents to the Emergency Department with a fever and abdominal pain for four days and a headache for the past 24 hours. She and her husband recently visited a hobby/petting farm with their two children. On examination, she has a temperature of 38°C, pallor, and a purpuric rash on her legs and abdomen. Her blood pressure is 150/90 mmHg. The rest of the examination is unremarkable. Laboratory investigations reveal thrombocytopenia, anemia, elevated LDH, and elevated creatinine. A CT scan of the brain and an abdominal ultrasound scan are both normal. Lumbar puncture is not performed due to the thrombocytopenia. What is the most likely diagnosis?

MRCP2-2456

A 67-year-old woman arrives at the Emergency department with involuntary movements and hemisensory loss. Her blood work reveals a platelet count of 5 ×109/L (150-400), a haemoglobin level of 60 g/L (115-165), and a creatinine level of 160 µmol/L (60-110). A blood smear conducted urgently shows an abundance of red cell fragments. The patient is suspected to have thrombotic thrombocytopenic purpura and is transferred to the ICU. What is the most appropriate treatment option for this patient?

MRCP2-2457

A 28 year old female who is 10 days post-partum (spontaneous vaginal delivery) arrives at your medical admissions unit with her partner who is concerned about her confusion. She is unable to provide any history, but her partner reports that her condition has gradually worsened over the past few days. Her vital signs are as follows: temperature 38ºC, pulse 90/min, blood pressure 154/88 mmHg, respiratory rate 16/min, sats 99% on room air.

Upon examination, she appears pale. Her chest is clear, and her abdomen is soft and non-tender. She has multiple bruises on her arms. Her blood test results are pending.

What is the most probable diagnosis?

MRCP2-2458

A 19-year-old female arrives at the emergency department complaining of dark urine. She was recently diagnosed with ‘mono’ after experiencing a sore throat that was confirmed by swab testing. Her symptoms began nine days ago, and she had been recovering well until she noticed the dark urine after taking a walk in the park. She returned home after it started raining heavily and became very cold, and she also experienced abdominal cramping. She has no medical history, takes only oral contraceptives, and has no allergies.

The following blood tests were conducted:
– Hemoglobin (Hb): 101 g/l
– Platelets: 379 * 109/l
– White blood cells (WBC): 5.1 * 109/l
– Bilirubin: 43 µmol/l
– Alkaline phosphatase (ALP): 161 u/l
– Alanine transaminase (ALT): 15 u/l
– Blood film: spherocytes

What is the most appropriate diagnostic test to determine the cause of her symptoms?