Archives: MRCP Part 2

MRCP2-2369

A 32-year-old female presents to the antenatal clinic at 24 weeks gestation with complaints of general malaise, fatigue, and shortness of breath at rest. Her partner reports that she has been vague and mildly confused at times over the past 24 hours. This is her first pregnancy and has been uncomplicated thus far. At her initial appointment, she did not report any significant medical history. The dating ultrasound scan did not detect any abnormalities, and her full blood count was within normal limits.

During the examination, her blood pressure was 122/80 mmHg, slightly higher than her booking blood pressure of 116/77 mmHg. Her temperature was 37.8°C, and heart sounds were normal. Her chest was clear, and abdominal examination was unremarkable. However, she was disorientated in date, day, and time, and seemed very agitated. A purpuric rash was also observed over her shins.

She was admitted to the antenatal ward, and blood tests were ordered. The results showed a haemoglobin level of 48 g/L (115 – 165), reticulocytes at 16% (0.5 – 2.4), white cell count at 12.0 ×109/L (4 – 11), and platelets at 6.0 ×109/L (150 – 400). A peripheral blood film showed gross red cell fragmentation with polychromasia, numerous spherocytes, and nucleated red cells. Her urinalysis showed blood and protein at +1.

What is the appropriate management for this patient?

MRCP2-2370

A 16-year-old male from India presents with a 10-hour history of priapism. He has a medical history of intermittent back and abdominal pain. During examination, he appears pale and has a fever of 39°C. He also has an enlarged smooth liver and a painful engorged penis. Laboratory tests reveal a haemoglobin level of 85 g/L (130-180), MCV of 81 fL (80-96), white cell count of 12.2 ×109/L (4-11), and platelets of 450 ×109/L (150-400). What is the most likely diagnosis?

MRCP2-2371

A 23-year-old man with sickle cell disease presents to the Emergency Department with worsening pain in his arms and legs over the past 48 hours. He also reports a painful sustained erection that started 6 hours ago. He has no significant past medical history and is currently taking paracetamol, ibuprofen, folate, and penicillin. He has never received regular transfusions and has only been admitted once before for a crisis.

On examination, his heart rate is 108 beats per minute and his blood pressure is 130/90 mmHg. His oxygen saturation is 97% on room air and he is afebrile. There is no swelling or erythema of his limbs, but they are tender to touch. He continues to have a painful erection, but there is no sign of ischaemia.

His chest x-ray is clear and his blood tests show a hemoglobin level of 80 g/l, platelets of 320 * 109/l, and a CRP of 12 mg/l.

He is given intravenous fluids and diamorphine for pain relief, which improves his limb pain but not his painful erection.

What is the most appropriate next step in management?

MRCP2-2372

A 45-year-old male patient has been referred to the endocrinology clinic due to newly diagnosed, poorly controlled diabetes mellitus. He is also experiencing lethargy and has recently developed erectile dysfunction. During the examination, the patient reports bilateral knee discomfort, but no other pathology is detected except for a 3 cm hepatomegaly. Blood tests reveal abnormal liver function. What should be the next step in managing this patient’s condition?

MRCP2-2373

A 25-year-old man presents with diffuse bruising, abdominal pain, and loss of appetite. He feels unwell and has no history of taking any medications, does not use dietary supplements, and does not use illicit drugs. His past medical history is negative for any prior illnesses or hospitalisations. No family history of any bleeding disorders.

On examination, he has a heart rate of 115 bpm with a blood pressure of 130/75 mmHg. His respiratory rate is 18 breaths per minute and he is afebrile with a temperature of 37.2ºC. His abdominal exam demonstrates rebound tenderness in the right lower quadrant.

Investigations:

Hb 13.7 g/L (135-180)
Platelets 48 * 109/L (150 – 400)
WBC 5 * 109/L (4.0 – 11.0)
Haematocrit 41% (41-50%)
INR 1.1 (0.9-1.2)
Fibrinogen 2.2 g/L (2 – 4)

A diagnosis of acute appendicitis is made and the general surgical team decides that the patient needs to be taken to theatre for an urgent laparoscopic appendectomy.

What is the next best step in managing this patient?

MRCP2-2374

A 85-year-old man is being seen by his oncologist for monitoring of his recently diagnosed chronic lymphocytic leukaemia (CLL). He is scheduled to undergo genetic testing to determine his prognosis. What factors are associated with a poor prognosis in his condition?

MRCP2-2375

A 54-year-old woman presents to her GP with complaints of fatigue and bruising. She has no significant medical history. After an abnormal full blood count, she is referred to the haematology clinic. The following are her blood results:

– Hb: 112 g/L (Female: 115 – 160 g/L)
– Platelets: 150 * 109/L (150 – 400 * 109/L)
– WBC: 25.3 * 109/L (4.0 – 11.0 * 109/L)
– Neuts: 4.0 * 109/L (2.0 – 7.0 * 109/L)
– Lymphs: 16.2 * 109/L (1.0 – 3.5 * 109/L)
– Mono: 3.0 * 109/L (0.2 – 0.8 * 109/L)
– Eosin: 1.1 * 109/L (0.0 – 0.4 * 109/L)

Her LDH level is 250 U/L (140 – 280 U/L). Multicolour flow cytometry assay reports CD20+, CD23+, and CD5+ expression. Fluorescence in situ hybridization (FISH) reveals a deletion in the short arm of chromosome 17.

What is the feature associated with a poor prognosis in this case?

MRCP2-2360

A 35 year old patient presents to the acute medical unit with a 4 hour history of worsening chest pain. He reports feeling more fatigued than usual lately, experiencing increased breathlessness, and noticing dark discolouration of his urine, particularly in the mornings. The patient has a medical history of deep vein thrombosis (DVT) in his left leg, which was treated with 6 months of warfarin therapy 3 years ago.

An immediate ECG reveals anterior ST depression and T wave inversion.

CXR: unremarkable

Blood tests:

Troponin I 1.2 µg/L (elevated)
Hb 100 g/l
Plt 99 x10^9/l
WCC 6.0 x10^9/l
Na+ 137 mmol/l
K+ 4.8 mmol/l
Urea 7 mmol/l
Creatinine 82 µmol/l

Due to the patient’s cardiac-sounding chest pain, ECG abnormalities, and elevated cardiac enzymes, he is taken to the cath lab. The coronary angiogram reveals thrombosis of the left anterior descending artery, which is aspirated during the procedure. No significant atherosclerotic plaque formation or stenosis of the coronary arteries is identified.

Based on this patient’s presentation, what would be the most useful investigation to perform next?

MRCP2-2361

A 67-year-old man presents with back pain. He was recently diagnosed with peripheral neuropathy but the cause is unknown. He has no other medical history and takes no regular medications. During examination, tenderness of his lumbar spine is noted along with hepatosplenomegaly and hyperpigmentation of his skin. Blood tests reveal low hemoglobin, elevated creatinine, and a monoclonal band with an IgG light chain spike. A whole body MRI scan shows an osteoblastic lesion in the L4 vertebrae. What is the most likely diagnosis?

MRCP2-2362

A 72-year-old retired steel industry worker has been diagnosed with renal cell carcinoma. His blood test results show significant abnormalities:
– Haemoglobin (Hb) 203 g/L (130-180)
– Haematocrit (PCV) 0.60% (0.40-0.52)
– Mean cell volume (MCV) 90 fL (84-96)
– White cell count (WBC) 10 ×109/L (4.0-11.0)
– Platelets 400 ×109/L (150-450)

Which of the following symptoms can be attributed to the above blood test results?