Archives: MRCP Part 2

MRCP2-2412

A 65-year-old male with a history of chronic lymphocytic leukaemia (CLL) and currently under monitoring visits his general practitioner with new symptoms. He reports experiencing fevers and waking up with a wet pillow. Additionally, he has a dry cough and has lost some weight but otherwise feels fine. He has a medical history of hypertension and type 2 diabetes and was previously taking amlodipine, metformin, and tolbutamide, but stopped two weeks ago due to a prescription issue. He is a smoker and drinks 10-14 units of alcohol per week.

During the examination, the patient’s temperature is 37.9ºC, and his chest is clear. He appears clammy, but there are no visible rashes.

Lab results show:
– Hb: 124 g/l
– Platelets: 378 * 109/l
– WBC: 13.2 * 109/l
– Neuts: 11.2* 109/l
– CRP: 9 mg/L
– LDH: 857 U/L (normal range 180-360 U/L)

What is the most likely explanation for the patient’s symptoms and lab results?

MRCP2-2413

A 54-year-old male presented to the rapid access Transient Ischaemic Attack (TIA) clinic with new onset left leg and arm weakness that lasted for 90 minutes and fully resolved with no residual defect. He had a past medical history of hypertension, obstructive sleep apnoea, and a left-sided deep vein thrombosis eight years ago. On examination, he had obvious truncal obesity and a flushed complexion. Initial investigations revealed abnormal blood results, including high Hb, Hct, and platelets, as well as elevated WBC with a high percentage of neutrophils. The most appropriate next investigation to lead to the underlying diagnosis would be:

What is the most appropriate next investigation for this patient?

MRCP2-2414

A 55-year-old female presents to pre-assessment surgical clinic prior to an elective arthroscopy of her left knee that she injured while hiking. She is otherwise asymptomatic, has no other medical history and is a lifelong non-smoker. She drinks 8 units of alcohol per week. Recently, she has experienced hot flashes and irregular periods, which she puts down to undergoing the menopause. Examination of her cardiovascular, respiratory and abdominal systems are unremarkable.

Her blood results are as follows:

Hb 95 g/l
MCV 59 fl
Platelets 389 * 109/l
WBC 4.5 * 109/l
Red cell distribution width 13% (normal range 11.5-14.5%)
Blood film anisocytosis, hypochromia, target cells

Which investigation is most likely to reveal the diagnosis?

MRCP2-2415

A 75-year-old male is referred to the hospitals ambulatory care clinic by his GP after 3 months of increasing generalised malaise and ‘lack of energy’ over the past three months. He lives with his wife and until 12 weeks ago, continued to play golf and go for walks in the park with no limitations to his exercise tolerance. Now, he feels ‘tired all the time’ but denies any problems with his mood. He has no history of psychiatric disorders. His past medical history includes hypertension (well controlled on lisinopril alone), hypercholesterolaemia (well controlled on atorvastatin) and chronic lymphocytic leukaemia, diagnosed 2 years ago and not requiring treatment.

On examination, he has warm peripheries with bilateral conjunctival pallor. He is alert and comfortable at rest. Non-tender lymphadenopathy in bilateral cervical chains. His cardiovascular, respiratory, abdominal and neurological examinations are otherwise unremarkable. His blood results are as follows:

Hb 70 g/l
MCV 98 fl
Platelets 75 * 109/l
WBC 65.0 * 109/l
Neut 3.5 * 109/l
WBC 61.5 * 109/l
Reticulocytes 12%
Blood film and direct agglutination test lymphocytosis, smudge cells, reticulocytes, red cell agglutination at physiological temperature

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

MRCP2-2416

A 16-year-old male is under investigation for a prolonged history of malaise. He has a past medical history of recurrent episodes of anemia, but the cause has never been determined. There is no significant past or family history, and aside from the malaise, he reports no other symptoms. On examination, he presents with mild jaundice, a blood pressure of 120/75 mmHg, and a pulse rate of 80 beats per minute. His spleen is palpable 6 cm below the left costal margin, but no other abnormalities are found. The results of his investigations are as follows:

– Haemoglobin: 84 g/L (130-180)
– MCV: 76 fL (80-96)
– MCH: 29 pg (28-32)
– MCHC: 40 g/dL (32-35)
– White cell count: 11.0 ×109/L (4-11)
– Neutrophils: 7.0 ×109/L (1.5-7)
– Lymphocytes: 3.2 ×109/L (1.5-4)
– Monocytes: 0.5 ×109/L (0-0.8)
– Eosinophils: 0.2 ×109/L (0.04-0.4)
– Basophils: 0.1 ×109/L (0-0.1)
– Platelets: 366 ×109/L (150-400)
– Reticulocyte count: 9.0%
– Serum ferritin: 45 g/L (15-300)
– Serum folate: 1.2 g/L (2.0-11.0)
– Direct Coombs test: Negative
– Osmotic fragility test: Increased osmotic fragility
– Serum sodium: 139 mmol/L (137-144)
– Serum potassium: 4.5 mmol/L (3.5-4.9)
– Serum urea: 4.5 mmol/L (2.5-7.5)
– Serum creatinine: 60 µmol/L (60-110)
– Serum aspartate aminotransferase: 30 U/L (1-31)
– Serum alkaline phosphatase: 56 U/L (45-105)
– Serum total bilirubin: 102 µmol/L

MRCP2-2417

A 55 year old woman presents to the haematology clinic with a persistent erythrocytosis that has been monitored by her General Practitioner for the past 6 months. She is asymptomatic and denies any headaches or visual changes. Her medical history is significant only for internal fixation of a tibial fracture sustained in a car accident 5 years ago. There is no significant family history of venous thrombosis or ischaemic heart disease. She takes no regular medications and works as an accountant. She is a lifelong non-smoker and drinks approximately 10 units of alcohol per week.

The haematology team requests further investigations, including Hb # g/dl, Platelets # * 109/l, and WBC # * 109/l. The results show a haemoglobin level of 18.7 g/dL, white cell count of 6.1* 109/l, and platelets of 276 * 109/l. The patient’s packed cell volume is 0.57, and her serum erythropoietin level is 3 U/L (reference 0-19). A JAK 2 V617F mutation is positive, and an abdominal ultrasound shows mild-moderate splenomegaly.

Given these findings, what is the appropriate management for the patient’s erythrocytosis?

MRCP2-2418

A 44-year-old female teacher with no medical history is referred for investigation of a paraprotein found during a routine check-up. She is asymptomatic and has no family history of illness. On examination, her vital signs are stable, and there are no palpable lymph nodes or organomegaly. Neurological examination is unremarkable. Investigations reveal the presence of an M band and an IgG kappa paraprotein level of 12 g/l, as well as 25% plasma cells in the bone marrow aspirate and a serum corrected calcium level of 2.24 mM. What is the most appropriate management plan?

MRCP2-2419

A 42-year-old man presents to the haematology day unit 55 days after receiving a bone marrow transplant from his sibling for acute myeloid leukaemia. He has been doing well until he noticed dark urine three days ago, followed by a fever and confusion. On examination, he has a high temperature, rapid pulse, and yellow sclerae. His blood tests show low haemoglobin and platelet counts, reactive white cells, and elevated levels of creatinine, bilirubin, and lactate dehydrogenase. His ciclosporin level is also high. What is the most likely diagnosis?

MRCP2-2401

A 59-year-old male presents to the haematology outpatient department with widespread bruising. He has no significant medical history, does not take regular medications, and does not smoke or drink alcohol. Upon examination, ecchymoses are observed throughout his limbs, abdomen, and thorax. Blood tests reveal a hemoglobin level of 111 g/L, platelet count of 167 * 109/L, and a white blood cell count of 4.2 * 109/L. The patient’s APTT is 61 seconds, and a mixing study is abnormal, indicating the presence of a factor VIII inhibitor. What is the most likely diagnosis?

MRCP2-2402

A 30-year-old patient presents to a remote emergency department with facial swelling and abdominal pain. The patient has a medical history of C1 esterase inhibitor deficiency and has recently arrived from Russia without their regular medications. The patient denies smoking or drinking alcohol.

Vital signs are within normal limits with a heart rate of 90 beats per minute, blood pressure of 120/80 mmHg, respiratory rate of 16/minute, oxygen saturation of 97% on room air, and temperature of 37.2ºC.

Physical examination reveals facial swelling without airway obstruction and mild abdominal tenderness without peritonism. No rash or wheezing is present.

Unfortunately, there is no IV C1-inhibitor concentrate available in this rural location. What is the most appropriate medication to terminate the attack based on the patient’s clinical history?