Archives: MRCP Part 2

MRCP2-2435

A 32 year old man presents to the emergency department with central abdominal pain and vomiting that is unresponsive to IV morphine. He has been seen by surgeons earlier in the day for an acute abdomen, but a CT scan and blood tests revealed no surgical cause for his symptoms. Interestingly, the patient has presented to the emergency department five times in the past two years with similar problems, but no cause has ever been found and he was discharged with analgesia after a day or two. On examination, the patient has a generally tender abdomen with voluntary guarding and a rash on the back of his hands, neck, and cheeks consisting of several small fluid-filled bullae. His past medical history includes depression treated with citalopram and a short psychiatric inpatient stay for an episode of psychosis. What is the most likely diagnosis?

MRCP2-2403

A 20-year-old male with T-cell acute lymphoblastic leukemia is undergoing cytotoxic chemotherapy with the hyper-CVAD regimen. On the 14th day of treatment, his vital signs show a blood pressure of 100/60 mmHg, a heart rate of 120 bpm, and a fever of 39°C accompanied by chills and rigors.

What would be your initial course of action in this scenario?

MRCP2-2404

A 65-year-old woman visits her doctor complaining of a lump in her armpit that she noticed two months ago and feels is increasing in size. She denies experiencing fever, night sweats, weight loss, or fatigue. The doctor orders some blood tests, as shown below.

Hemoglobin: 116 g/L (normal range for females: 115-160 g/L)
Platelets: 160 * 109/L (normal range: 150-400 * 109/L)
White blood cells: 72 * 109/L (normal range: 4.0-11.0 * 109/L)
Neutrophils: 5 * 109/L (normal range: 2.0-7.0 * 109/L)
Lymphocytes: 66 * 109/L (normal range: 1.0-3.5 * 109/L)
Blood film: smudge cells

Which of the following factors would suggest a poor prognosis for this patient?

MRCP2-2405

A 26-year-old man is rushed into the resuscitation room with severe dyspnoea. He admits to inhaling some unknown substances at a party earlier in the evening. On examination, he has blue-tinged peripheries with blue lips and tip of nose but appears relatively calm. His oxygen saturation is at 90% on 6 litres of oxygen and his heart rate is at 120 beats per minute. An arterial blood gas is taken while he is on 6 litres of oxygen, with the following results:

pH 7.40 (7.35-7.45)
paO2 18 (11-13)
paCO2 4.6 (4.5-6)
methaemoglobin 38% (1-3%)

What substance is most likely responsible for his condition?

MRCP2-2406

A 75-year-old man presents to the haematology clinic with a complaint of anaemia. He reports feeling progressively fatigued and experiencing shortness of breath for the past four months. Additionally, he has been waking up drenched in sweat one or two nights per week for the last month. He has a medical history of hypertension and COPD, but his weight has remained stable.

During the examination, the patient appears pale, but his heart sounds are normal and his chest is clear. He does not have ankle oedema, and his JVP is not raised. His abdomen is soft, but he does have splenomegaly 3 cm below the costal margin with no hepatomegaly.

The patient’s GP sent over test results, which show a Hb of 92 g/l, platelets of 143 * 109/l, and WBC of 4 * 109/l, among other values. The blood film shows anisocytosis with mild hypochromia, tear drop cells, and mild thrombocytopenia with no platelet clumping. A chest x-ray reveals mildly hyperexpanded lung fields with no focal consolidation, masses, or lymphadenopathy. Upper GI endoscopy and colonoscopy both appear normal.

To confirm the likely diagnosis, which mutation must be present?

MRCP2-2407

A 24-year-old man presents to the emergency department with acute illness for the past 72 hours. He has been experiencing fatigue for the last month and has had night sweats and several colds. Over the last three days, his condition has worsened, with shivering and vomiting. He has also noticed bruising on his forearms and thighs. During the examination, he appears drowsy and has a temperature of 38.5ºC. His blood pressure is 90/50 mmHg, heart rate 120/min, and he is peripherally shut down with a cap refill time of 5 seconds. He has conjunctival pallor. The emergency department administers IV fluids and antibiotics. His blood test results show:

Hb 89 g/l
Platelets 43 * 109/l
WBC 13.0 * 109/l
Neutrophils 9.0 * 109/l
D-Dimer 5.8mg/L (<0.5)
INR 8.5
PT 89 seconds (9-12)
APTT ratio 1.7 (0.8-1.2)
Fibrinogen 0.1g/L (1.5 – 4.5)
Blood film Faggot cells seen

Na+ 138 mmol/l
K+ 5.8 mmol/l
Urea 18 mmol/l
Creatinine 195 µmol/l
CRP 170 mg/l

Bilirubin 8 µmol/l
ALP 102 u/l
ALT 300 u/l
Albumin 38 g/l

He is transferred to ICU for inotropic support. Fresh frozen plasma corrects his coagulopathy. Haematology is consulted, and a bone marrow analysis is performed. Cytogenetics reveals a translocation of chromosomes 15 and 17. What is the appropriate treatment for this patient?

MRCP2-2408

A 32-year-old male presents with a 5 day history of bloody diarrhoea and vomiting, fevers and associated with occasional abdominal cramps. He reports no other symptoms. He reports no previous history of gastrointestinal disease; there is no family history of inflammatory bowel disease. He has no past medical history except for a left knee arthroscopy following an injury playing football 8 months ago. He is a lifelong non-smoker, drinks 14 units of alcohol a month, has not travelled abroad in the past year and last ate outside of his home a week ago during a barbecue at his brother’s house.

On examination, he appears dehydrated. There is mild generalised abdominal tenderness with increased bowel sounds. Respiratory and cardiovascular examinations were unremarkable. His blood tests are as follows:

Hb 92 g/l
MCV 90fl
Platelets 49 * 109/l
WBC 14.2 * 109/l
Neutrophils 12.8 * 109/l
Blood film schistocytes, reticulocytosis
Direct antiglobulin test negative
Urea 14.9 mmol/l
Creatinine 159 µmol/l
CRP 82 mg/l

What is the cause of this patient’s blood abnormalities?

MRCP2-2409

A 76-year-old patient presents to the haematology outpatient clinic with a lump in their neck and widespread lymphadenopathy in the cervical, inguinal, and axillary regions. The patient has no past medical history.

Based on the presentation, what is the most crucial test to confirm the diagnosis?

MRCP2-2410

A 25 year-old medical student of Italian descent returns from a trip to India and presents with fever, headache, and myalgia one week later. What additional blood test is crucial for managing this condition?

Investigations reveal a hemoglobin level of 10.1 g/dl, MCV of 101.2 fl, platelets at 43 x10^9/l, and WCC at 6.1 x10^9/l. Sodium levels are at 134 mmol/l, potassium at 4.6 mmol/l, urea at 3.8 mmol/l, and creatinine at 80 mol/l. ALT is at 44 IU/l, ALP at 78 IU/l, bilirubin at 33 mol/l, and albumin at 38 g/l. Thick and thin blood films show Plasmodium ovale parasites with red cells.

MRCP2-2411

A 16-year-old boy with severe haemophilia A (factor VIII level < 1%) is currently hospitalized due to a swollen and painful left knee with limited movement in all directions. His latest inhibitor screen came back negative. What is the most suitable product to manage this suspected haemoarthroses in this case of haemophilia A?