A 32-year-old woman comes to the gastroenterology clinic for follow-up. She was diagnosed with coeliac disease 2 years ago and has been experiencing severe fatigue, muscle aches, and weakness in her proximal muscles for the past few months. During the examination, her blood pressure is 112/70 mmHg, and her pulse is regular at 75 beats per minute. Proximal muscle weakness is confirmed.
Lab results show a calcium level of 2.0 mmol/l and an alkaline phosphatase level of 275 IU/l. What is the most useful next investigation?
MRCP2-4548
A 20-year-old man has been referred to the Rheumatology Clinic due to a long history of pain in his back and knee joints. He first experienced recurrent back and wrist pain at the age of 7 and was treated for possible juvenile arthritis, which often responded to analgesia. However, the disease has been relapsing and remitting over the years, and since last year, the back pain has been constant all over his spine and has not responded to analgesia.
Despite several investigations in the past, including X-rays of the spine and knee, rheumatoid factor, antinuclear antibody, and autoimmune profile, all results were reported as normal. He had a normal childhood with no illness, and there is no family history of note. He has also seen dermatologists for an abnormal dark-brown pigmentation in his ears and sclera, but no cause was found.
During examination, his knees are swollen and painful, and he has tenderness all over his spine. Both sclera and ears show an abnormal dark brown pigmentation. Further investigations reveal abnormal results in his haemoglobin, white cell count, platelets, and urinalysis.
What is the probable underlying diagnosis?
MRCP2-4551
A 68-year-old man with a history of Rheumatoid Arthritis presents with weakness and numbness on the left side of his face. Despite negative CT and MRI scans, he was treated for a potential stroke. He is now pyrexial with proteinuria and a history of resolved foot drop on the right side. On examination, he has no notable findings except for the facial and trigeminal nerve deficits. His blood work shows elevated CRP and ANCA positivity. What is the most appropriate investigation to determine the cause of his symptoms?
MRCP2-4552
A 70-year-old male presents to the emergency department after experiencing two episodes of loss of consciousness within the past 48 hours. His wife witnessed both episodes, which occurred while he was sitting in his chair at home. There was no observed limb jerking, urinary incontinence, or tongue biting. The patient reports difficulty walking short distances, which he attributed to his age. He has no significant medical history, is a non-smoker, and lives with his wife. On examination, he has a significant thoracic kyphosis and limited spinal lateral flexion and bilateral spinal rotation. His cardiovascular exam reveals heart sounds I and II with an early diastolic murmur, and his respiratory exam reveals fine inspiratory crackles at both apices. His lying and standing blood pressures are normal. A CT head shows mild microangiopathic disease. The patient is alert and comfortable, but attached to cardiac telemetry. What would you expect to see on his ECG?
MRCP2-4553
A 22-year-old male patient visits his GP complaining of low back pain that has been ongoing for a few months. He reports stiffness in the back upon waking up, which lasts for more than an hour. The patient is an avid sports enthusiast and notes that his symptoms improve with exercise. However, sitting at his desk for extended periods seems to worsen his symptoms. The patient has no significant medical history except for a bout of uveitis about a year ago.
What initial investigation would be the most appropriate to confirm the diagnosis?
MRCP2-4554
A 23-year-old patient with SLE for the past five years complains of sudden onset of shortness of breath over the last three days. On examination, the pulse rate is 100/min, BP 120/80 mm Hg, and SaO2 of 94% on air. All other organ system examinations are normal. FBC, U&E, and INR are within normal limits, but D-dimers are positive. A chest radiograph and ECG show no abnormalities. What is the most suitable investigation in this case?
MRCP2-4555
A 30-year-old woman delivers a baby who is diagnosed with complete heart block and needs a pacemaker. What antibody is expected to be found in the mother’s serum?
MRCP2-4556
A 59-year-old man presents with Raynaud’s phenomenon and progressive difficulty in climbing stairs. He has also noticed cracking and peeling of the skin on the fingertips and on the lateral aspect of his hands.
On examination, the power is 4/5 proximally, with intact reflexes and downward going plantars.
Recent blood tests are as follows:
– Hb 131 g/L (130-180) – WBC 9.9 ×109/L (4-11) – Neutrophils 88% (40-75) – Platelet 196 ×109/L (150-400) – ESR 66 mm/hr (0-20) – CK 1200 IU/mL (24-195) – CRP 131 mg/L (<10)
Urea, electrolytes and creatinine are normal. Liver function tests normal. Anti-nuclear antibody negative. Anti-dsDNA antibody negative. Anti-Ro/La antibody negative. Anti-Jo1 antibody positive.
What is the diagnosis?
MRCP2-4557
A 45-year-old non-smoking woman presents with weakness in her left arm (power 3/5) and left-sided facial drooping. These symptoms resolve within an hour of being examined by the admitting doctor. She has normal heart sounds, peripheral pulses, and is in sinus rhythm. As part of her workup, she undergoes blood tests and other investigations. The results show thrombocytopenia, no schistocytes, and the following values: Hb 130 g/L (115-165), WBC 9.5 ×109/L (4-11), Neutrophils 72% (40-75), Platelet 75 ×109/L (150-400), ESR 8 mm/hr (0-15), INR 1.0 (<1.4), aPTT 50 seconds (30-40 seconds), and aPTT did not normalize after addition of plasma. Urea, electrolytes, and creatinine are normal, and CT head and echocardiogram are also normal. What is the most likely cause of her symptoms?
MRCP2-4558
A 40-year-old man with a history of diabetes presented to the clinic with bilateral knee pain. On examination, he appeared suntanned with sparse body hair and the knees were swollen and tender, with limited range of movement. He works as an insurance salesman, is a non-smoker but drinks on most weekends, and is on insulin for the diabetes and also takes sildenafil occasionally for erectile dysfunction. The investigations revealed abnormal results for sodium, potassium, creatinine, albumin, bilirubin, ALT, AST, GGT, glucose, LH, FSH, and testosterone. Additionally, an X-ray of the knees showed calcification present. What is the most likely cause of the joint abnormality?