Archives: MRCP Part 2

MRCP2-2425

A 65-year-old man with rheumatoid arthritis presents with chest pain and breathlessness that has developed over the course of a week. Upon examination, the patient appears pale and jaundiced, with a pulse of 110 bpm and a raised jugular venous pressure. Crackles are audible throughout the chest, and a 3 cm spleen is palpable. An electrocardiogram shows widespread depression of ST segments. The following investigations were conducted: Haemoglobin (Hb): 49 g/l (normal range: 135 – 175 g/l)Mean corpuscular volume (MCV): 105 fl (normal range: 80 – 100 fl)Coombs’ test: IgG+Bilirubin: 45 µmol/l (normal range: 1 – 22 µmol/l)Lactate dehydrogenase (LDH): 1157 u/l (normal range: 140 – 280 u/l)How should these test results be interpreted?

MRCP2-2426

A 50-year-old man presents to the clinic with pain in his wrists and knees, as well as difficulty walking due to pain in his right knee. He also reports feeling more tired lately, experiencing constant thirst, and having abdominal pain mainly in the right upper quadrant, which worsens in the evenings. He smokes 20 cigarettes per day, drinks half a bottle of wine with his evening meal, and recently returned from a trip to Mozambique where he took precautions to avoid malaria. On examination, his wrist joints and knees are tender, and his right knee is swollen. An aspirate of his right knee reveals crystals with positive birefringence. Which investigation is most helpful in making a diagnosis for this patient?

MRCP2-2427

A 50-year-old self-employed carpenter who specializes in building custom furniture is referred to the Haematology Clinic due to complaints of fatigue and exhaustion. His General Practitioner has conducted a blood test and found that he is anaemic, with a haemoglobin (Hb) level of 99 g/l (normal value 135–175 g/l) and a mean corpuscular volume (MCV) of 68 (normal value 70–90 fl). The blood film report notes red cell dimorphism with polychromatophilic, stippled red blood cells. What is the most common diagnosis associated with these blood film findings?

MRCP2-2428

A 55-year-old man presents to his primary care physician with persistent headaches and blurred vision. These symptoms have been present for the past six months but have worsened recently. Upon further questioning, the patient also reports feeling fatigued and experiencing intermittent muscle aches.

One year ago, the patient was diagnosed with obstructive sleep apnea due to morbid obesity and was provided with non-invasive ventilation to use at night. However, the patient admits to rarely using this equipment due to discomfort with the tight face mask. Despite receiving dietary and lifestyle advice, the patient has gained 6 kg over the past year and has a BMI of 41 kg/m².

Neurological examination, including fundoscopy, is unremarkable, and there are no tender or inflamed joints. Blood tests ordered by the physician are detailed below.

– Hemoglobin: 195 g/L
– White blood cell count: 7.5 * 109/L
– Neutrophils: 5.7 * 109/L
– Lymphocytes: 0.9 * 109/L
– Platelets: 195 * 109/L
– Packed cell volume: 0.60
– Urea: 5.9 mmol/L
– Creatinine: 110 µmol/L
– Sodium: 135 mmol/L
– Potassium: 4.1 mmol/L
– eGFR: 68 ml/min

A review of a full blood count performed four months prior revealed an elevated PCV of 0.56 that went unnoticed. The patient was urgently referred to hematology for further management.

What is the most appropriate treatment for this patient’s erythrocytosis?

MRCP2-2429

A 42-year-old male presents with a 2-month history of increasing lethargy. His wife reports him to be not quite himself for the past 2 months now, with poor oral intake and poor appetite. He is a self-employed graphic designer but currently is unable to work due to his lethargy. He was previously treated for Hodgkin’s lymphoma 7 years ago and has since been in remission.

On examination, he has no conjunctival pallor, is dry on his mucous membranes and extremely lethargic. Firm, rubbery lymph nodes are noted in the right axilla. Cardiovascular examination reveals a soft systolic murmur, respiratory and abdominal examinations are unremarkable. He is a non-smoker and drinks alcohol only occasionally. His blood tests are as follows:

Hb 88 g/l
MCV 104 fl
Platelets 94 * 109/l
WBC 12.8 * 109/l
Red cell distribution 9% (normal 11.5-14.5%)
Blood film leucoerythroblastic with myeloblasts

What is the most likely cause of this patient’s anaemia?

MRCP2-2430

A 24-year-old medical student returned from Uganda early due to illness despite taking malaria prophylaxis and sleeping under a mosquito net. He had been using primaquine instead of doxycycline due to previous side effects. He presented with central abdominal pain and jaundiced sclera. On examination, he appeared pale and jaundiced with no cyanosis. Blood tests showed low haemoglobin, high white cell count, and elevated bilirubin. Heinz bodies, bite, and blister cells were also present on the peripheral blood film. What is the most likely diagnosis?

MRCP2-2431

A 25-year-old female presents with her first seizure episode on the labor ward, two days after giving birth to her first child through normal vaginal delivery. She reports experiencing fluctuating generalized headaches for the past three months but did not seek medical attention. She also had two fevers over 38ºC in the past 48 hours, with no dysuria, diarrhea, vomiting, productive cough, or signs of meningism. She has no medical history, is a lifelong non-smoker, and has been abstinent from alcohol for nine months, previously drinking four units per week. During her seizure, she experienced tonic-clonic jerking of all four limbs, loss of consciousness, and was terminated after 4mg of intravenous lorazepam after four minutes. On examination, she appears post-ictal but responds to voice despite being sleepy. Her blood results show low hemoglobin, low platelets, and elevated CRP and creatinine levels. A CT head with contrast showed no abnormalities. What is the most appropriate immediate management for this patient?

MRCP2-2432

An 86-year-old male is referred by the anaesthetic registrar after abnormal blood test results were noted during pre-assessment for an elective knee replacement. He is otherwise fit and well, independent with all activities of daily living and continues to drive. His past medical history includes diet controlled type 2 diabetes mellitus and hypertension.

During examination, he is alert and well, reports no discomfort, pain, or non-specific malaise. No skin bruises or conjunctival pallor are noted. A rubbery, non-tender and firm 3cm lymph node in the left cervical chain and non-tender splenomegaly at 8 cm below the costal margin are observed. His chest is clear and normal heart sounds are noted.

The patient’s blood tests are as follows, with blood tests from his GP 6 months ago in brackets:

– Hb 89 (95) g/l
– Platelets 78 (76) * 109/l
– WBC 67 (32) * 109/l
– Blood film mature lymphocytes and smudge cells

What is the most appropriate treatment?

MRCP2-2433

A 25-year-old man presents with a sudden loss of strength in his right leg that occurred 24 hours ago. He has no significant medical history, does not smoke, and has no family history of stroke. Physical examination reveals increased tone and brisk reflexes in the right leg and a 12 cm splenomegaly. A CT scan of the head is normal. Laboratory tests show a hemoglobin level of 130 g/L, a white blood cell count of 7.5 × 10^9/L, and a platelet count of 250 × 10^9/L. A blood film shows anisocytosis and poikilocytosis. Bone marrow examination reveals a translocation between chromosomes 9 and 22. What is the most likely diagnosis?

MRCP2-2434

A 72-year-old man with a lengthy history of rheumatoid arthritis comes in for a check-up. He has been experiencing weight loss and several instances of dark urine, but his bowel movements are normal. He confesses to drinking 20 units of alcohol per week and has previously resided in tropical regions, but has not traveled abroad recently.

During the examination, he weighs 80 kg and has a palpable spleen. His liver function tests were normal, except for an elevated total bilirubin. Urine analysis revealed urobilinogen and urosiderin, but no bilirubin or red blood cells. His hemoglobin was reduced to 100 g/l, there was an increase in spherocytes, and both haptoglobins and platelets were reduced.

What is the next best investigation to conduct in this scenario?