Archives: MRCP Part 2

MRCP2-2446

A 32-year-old male presents to the emergency department with complaints of shortness of breath. He has been feeling unwell for the past week with a headache, malaise, and lethargy. He felt breathless this afternoon, which prompted his visit. During the review of his symptoms, he also mentions experiencing general abdominal pain and diarrhea yesterday. He is generally healthy, does not take any regular medications, and is a non-smoker. He admits to drinking one or two beers every evening and occasionally more on weekends. He is a high school teacher and lives with his wife and two young children, none of whom have been unwell recently. Upon examination, he has a temperature of 38.9ºC, a heart rate of 105 beats/minute, and a blood pressure of 105/70 mmHg. His respiratory rate is 26 breaths/minute, and his oxygen saturation is 92% breathing room air. A few crepitations bibasally are heard upon auscultation of his chest. Routine blood tests are performed, revealing the following results:

Hb 109 g/L
MCV 105 fL
Platelets 390 * 109/L
WBC 16.5 * 109/L
CRP 240 mg/L
Bilirubin 50 µmol/L
ALT 40 u/L
ALP 135 u/L

What is the most likely diagnosis?

MRCP2-2447

A 35-year-old female presents to the outpatient haematology clinic with a falling white cell count. She had previously seen her GP eight weeks ago complaining of fatigue and joint/muscle pains after a viral illness. Her screening blood tests revealed a white cell count of 2.6 *10^9 g/dl, which decreased to 1.9 *10^9 g/dl over the next four weeks. Examination at the clinic was unremarkable, and initial investigations revealed neutropaenia and low B12 levels. What is the most appropriate management option for this patient?

MRCP2-2448

A 35-year-old patient presents to the emergency department feeling extremely fatigued and exhausted for the past week. He has been experiencing shortness of breath on exertion and can only walk a few hundred yards before becoming breathless. He has a history of sickle cell disease and is currently under the care of the Haematology team at the hospital. Upon examination, his vital signs are stable, but he becomes noticeably short of breath with minimal movement.

His blood tests reveal:

Hb 65 g/l
Platelets 46 * 109/l
WBC 2.5 * 109/l
Neuts 1.2 * 109/l
Haptoglobins 1.9 g/L (0.3-2.0)
Reticulocytes 8.9 x10^9/L (25-80)

Na+ 136 mmol/l
K+ 3.9 mmol/l
Urea 7.4 mmol/l
Creatinine 78 µmol/l
CRP <3 mg/L(<10)
LDH 200 IU/L (200-500)

Bilirubin 4 µmol/l
ALP 89 u/l
ALT 34 u/l
Albumin 39 g/l

His chest x-ray appears normal. Upon further questioning, he reveals that his 6-year-old son was unwell three weeks ago and was diagnosed with a viral illness by their GP. What is the most likely cause of his abnormal blood results?

MRCP2-2449

A 63-year-old man presents to the haematology clinic for review of his test results. He has been experiencing fatigue and night sweats for the past three months. Upon examination, he appears pale and has a palpable spleen that is mildly tender on palpation, measuring 4 cm below the costal margin. His medical history only includes osteoarthritis.

The following are his test results:

– Hb: 89 g/l
– Platelets: 205 * 109/l
– WBC: 5 * 109/l
– Neuts: 3.6 * 109/l
– Lymphs: 1.2 * 109/l
– Na+: 140 mmol/l
– K+: 4.0 mmol/l
– Urea: 5.8 mmol/l
– Creatinine: 72 µmol/l
– CRP: 3 mg/l

Blood film showed anisocytosis with mild hypochromia and tear drop cells. CT chest/abdomen/pelvis reveals splenic enlargement and a 1 cm simple right renal cyst, but no suspicious mass lesions or lymphadenopathy. Bone marrow biopsy shows fibrosis.

What is the recommended initial therapy for this patient?

MRCP2-2450

A 38-year-old woman has been admitted to the ICU two days after receiving her third cycle of chemotherapy for malignant ovarian cancer. She had been discharged without complications but developed a fever and was admitted to the Medical Admission Unit. Despite treatment for neutropaenic sepsis, she continued to deteriorate and developed hemiparesis and a decreased level of consciousness. Upon arrival at the ICU, her vital signs were unstable and she had evidence of schistocytes and normocytic normochromic anemia on blood film. What is the most appropriate immediate management step given the likely underlying diagnosis?

MRCP2-2420

A 43-year-old man presents to the Emergency department with a 24-hour history of lower abdominal pain. He had seen his general practitioner five days prior for cramps in his legs at night and was prescribed quinine sulphate, which he took only once. His medical history was unremarkable, except for a previous hospital admission with similar abdominal pain in his teens. On examination, he appeared jaundiced, and his blood pressure was 92/60 mmHg. Further investigations revealed abnormal blood counts, red cell anisocytosis, spherocytes, irregularly contracted red cells, and Heinz bodies inclusions. His serum total bilirubin was significantly elevated, and his serum C reactive protein was also elevated. What is the most likely diagnosis?

MRCP2-2421

A 55-year-old man has been diagnosed with high-grade non-Hodgkin’s lymphoma and has started his R-CHOP chemotherapy regimen. Two days after his chemotherapy, he complains of feeling increasingly weak, lethargic, and generally unwell. He has developed persistent vomiting and is unable to tolerate oral fluids. Despite having a history of recurrent gout, he has been unable to tolerate allopurinol.

During examination, he appears pale and unwell, with a respiratory rate of 28 per minute and a heart rate of 110 bpm. His blood pressure is 100/60 mmHg, and his JVP is raised by 4cm while lying at a 45-degree angle in the bed. Fine bibasal inspiratory crepitations are present in his chest, and pitting edema is present to mid-shins bilaterally. Neurological examination reveals normal tone and sensation to all limbs, but general weakness is noted.

The house officer has taken bloods, which reveal elevated levels of potassium, urea, creatinine, uric acid, and corrected calcium. His chest x-ray shows congested lung fields, and his ECG demonstrates tall T waves. Given his diagnosis, what is the most likely treatment for his hyperuricemia?

MRCP2-2422

A 23-year-old woman presents to the emergency department with her boyfriend. She complains of increasing shortness of breath and dizziness. She appears anxious and is holding onto her chest. There is no significant medical history and she has no known allergies.

Her vital signs are as follows:
Temperature 36.5ºC
Heart rate 120 beats/min
Blood pressure 118/70 mmHg
Respiratory rate 26 breaths/min
Oxygen saturation 88% on room air

Upon examination, her lips are blue. Her chest is clear with good air entry bilaterally and her heart sounds are normal. Peripheral pulses are present with a capillary refill of <2 seconds and her calves are soft and non-tender. Arterial blood gas results are as follows: pH 7.22 (7.35 – 7.45)
pO2 11.8 kPa (11 – 14.4)
pCO2 2.5 kPa (4.6 – 6.4)
Bicarbonate 15 mmol/L (22 – 29)
Chloride 98 mmol/L (95 – 108)
Lactate 1.1 mmol/L (0.5 -2.2)
Glucose 5.8 mmol/L (4 – 7)

Based on the likely diagnosis, what is the most appropriate next step in managing this patient?

MRCP2-2423

A 47-year-old man presents to his GP with complaints of tiredness, headaches, and an itchy rash after bathing. He used to smoke for 20 years but has been an ex-smoker for the past five years. He is currently taking a homeopathic medicine for stress due to his high-pressure office job. His family has a history of hypertension. On examination, the GP notes that he is plethoric and palpates his spleen two finger breadths below the left costal margin. His blood pressure is 138/89 mmHg.

The GP orders several investigations, and the results show a high haemoglobin and haematocrit level, elevated white cell count and neutrophils, and a platelet count above the normal range. His serum ferritin level is low, but his serum B12 and folate levels are within the normal range. His coagulation screen and chemistry results are all within normal limits.

What is the likely diagnosis for this patient?

MRCP2-2424

A 32-year-old hiker suffers a fractured femur and ruptured spleen while on a mountain trail. He receives 3 litres of crystalloid and 4 units of blood before undergoing a splenectomy and being transferred to Intensive Care. Upon arrival, his vital signs are as follows: pulse of 130 beats/minute, blood pressure of 95/45 mmHg, and temperature of 35°C. Blood gas analysis reveals a pH of 7.3, PaCO2 of 4.2 kPa, PaO2 of 23.3 kPa, and lactate of 4.2 mmol/L. Coagulation tests show an APTR of 1.3, INR of 1.1, fibrinogen of 0.15 g/L, and platelets of 80 ×109/L. During laparotomy, 2.5 litres of blood are discovered in the peritoneal cavity. What is the most likely explanation for his abnormal coagulation screen results?