Archives: MRCP Part 2

MRCP2-2351

A 42-year-old woman presents with abdominal distension, tenderness in the right upper quadrant, and pallor that has been going on for three days. Her blood count reveals a hemoglobin level of 71 g/L (normal range: 115-165), a white blood cell count of 2.5 ×109/L (normal range: 4-11), and a platelet count of 80 ×109/L (normal range: 150-400). Imaging studies confirm Budd-Chiari syndrome with complete thrombosis of the hepatic vein, and flow cytometry confirms paroxysmal nocturnal hemoglobinuria. What is the most appropriate treatment at this stage?

MRCP2-2352

A 32-year-old man presented to the hospital with a painful and swollen left leg. He also complained of recurring abdominal pain for several months. The patient had a history of a right calf deep vein thrombosis (DVT) six months ago, which was treated with warfarin for three months. He noticed that his urine had been darker than usual in the morning for the past two months.

Upon investigation, the patient’s haemoglobin was 85 g/L (130-180), white cell count was 2.5 ×109/L (4-11), and platelets were 75 ×109/L (150-400). His PT was 12 seconds (11.5-15.5), APTT was 35 seconds (30-40), serum total bilirubin was 29 µmol/L (1-22), serum AST was 20 U/L (1-31), and serum alkaline phosphatase was 80 U/L (45-105).

What is the most likely diagnosis?

MRCP2-2353

A 70-year-old man presents to the emergency department with a worsening headache and blurred vision over the past 2 weeks. Upon examination, there are no focal neurologic findings, and his vital signs are stable. However, bilateral retinal vein dilation and tortuosity with visible retinal haemorrhages are observed on fundoscopy.

The patient’s blood results reveal a low Hb level, decreased platelet count, elevated creatinine and urea levels, and increased IgM levels.

Based on the likely diagnosis, what is the urgent treatment required for this patient?

MRCP2-2354

A 70-year-old woman with breast cancer complains of a painful and swollen left calf. She has a history of vertebral body metastases and is currently taking denosumab as a prophylactic measure. Upon undergoing a Doppler ultrasound, it is revealed that she has a proximal deep vein thrombosis on the left side, which is her first experience with venous thromboembolism. What is the best course of action for her treatment?

MRCP2-2355

A 67-year-old male, with a history of metastatic prostate cancer, presents to the hospital with a 24-hour history of increasing pain, swelling, and redness in his left calf. He was diagnosed with prostate cancer five years ago and has been receiving treatment for metastasis for the past year. He has bone metastases.

During the examination, the patient appears weak and has some hair loss due to recent chemotherapy. Apart from the swollen, red, and tender left calf, and a fentanyl patch, there are no other significant findings.

The blood test results on admission are as follows:

– Hemoglobin (Hb): 98 g/l
– Platelets: 170 * 109/l
– White blood cells (WBC): 6.8* 109/l
– D-Dimer: 1350 µg/L (normal <500µg/L)
– Sodium (Na+): 134 mmol/l
– Potassium (K+): 4.2 mmol/l
– Urea: 6.8 mmol/l
– Creatinine: 105 µmol/l

The patient is diagnosed with a left leg deep vein thrombosis. Considering his current clinical condition, what is the most appropriate method of anticoagulation?

MRCP2-2356

A 37-year-old woman presents with anaemia due to menorrhagia. She has a medical history of fibroids, rhesus incompatibility during pregnancy 7 years ago, and Hodgkin’s lymphoma which has been in remission for 19 years.

She has a severe allergy to penicillin.

Her test results are as follows:

Hb 59 g/L Female: (115 – 160)
Platelets 350 * 109/L (150 – 400)
WBC 4.7 * 109/L (4.0 – 11.0)

The pregnancy test came back negative.

The consultant has requested that you prescribe 2 units of packed red cells for this patient.

What specific requirement must be considered for this patient’s blood transfusion?

MRCP2-2357

A 35-year-old female with a history of paranoid delusions for one month was prescribed phenothiazine. She now presents with a 10-day history of fever, chills, and malaise, along with increasing weakness and fatigue over the past two days. Upon examination, her temperature is 38.1°C, pulse is 100 beats per minute regular, and blood pressure is 110/76 mmHg. She has a respiratory rate of 25/min, and her chest shows dullness to percussion and decreased breath sounds at the left base. There is no splenomegaly.

The following investigations were conducted:
– Haemoglobin: 102 g/L (115-165)
– Haematocrit: 0.384 (0.36-0.47)
– MCV: 90 fL (80-96)
– White cell count: 0.9 ×109/L (4-11)
– Neutrophils: 0.3 ×109/L (1.5-7)
– Lymphocytes: 0.3 ×109/L (1.5-4)
– Monocytes: 0.01 ×109/L (0-0.8)
– Eosinophils: 0.01 ×109/L (0.04-0.4)
– Platelets: 210 ×109/L (150-400)
– Serum sodium: 131 mmol/L (137-144)
– Serum potassium: 3.3 mmol/L (3.5-4.9)
– Serum urea: 4.2 mmol/L (2.5-7.5)
– Serum glucose: 5.1 mmol/L (3.0-6.0)

The chest x-ray shows evidence of left basal consolidation. What is the most likely cause of her abnormal haematological indices?

MRCP2-2358

A 62-year-old man comes to the haematology clinic complaining of back pain that has persisted for the past 6 months. Upon examination, there are no signs of spinal cord compression or cauda equina syndrome.

The following are the results of his blood tests:

– Hb: 110 g/L (Male: 135-180, Female: 115-160)
– Platelets: 165 * 109/L (150-400)
– WBC: 6.2 * 109/L (4.0-11.0)
– Na+: 135 mmol/L (135-145)
– K+: 4.8 mmol/L (3.5-5.0)
– Urea: 10.8 mmol/L (2.0-7.0)
– Creatinine: 190 µmol/L (55-120)

Furthermore, his protein electrophoresis shows a monoclonal IgG of 38g/l.

What imaging modality is recommended for this likely diagnosis?

MRCP2-2359

A 32-year-old woman presents to the emergency department with fever and bruising. She has no past medical history and does not take any regular medications. She does not smoke or drink alcohol and works as a teacher.

Observations:

Heart rate 92 beats per minute
Temperature 38.2ºC
Blood pressure 168/100 mmHg
Respiratory rate 16/minute
Oxygen saturations 97% on room air

On examination, there is no meningism. You note that she is jaundiced but there are no signs of chronic liver disease. There are scattered petechiae on her arms, legs and abdomen.

Bloods tests:

Hb 70 g/L Male: (135-180)
Female: (115 – 160)
MCV 102 fL (80-96)
Platelets 35 * 109/L (150 – 400)
WBC 4.8 * 109/L (4.0 – 11.0)
Na+ 137 mmol/L (135 – 145)
K+ 4.1 mmol/L (3.5 – 5.0)
Urea 8.9 mmol/L (2.0 – 7.0)
Creatinine 150 µmol/L (55 – 120)
CRP 5 mg/L (< 5)
Bilirubin 55 µmol/L (3 – 17)
ALP 90 u/L (30 – 100)
ALT 22 u/L (3 – 40)
γGT 42 u/L (8 – 60)
Albumin 38 g/L (35 – 50)
Prothrombin time 12 seconds (10-14)

Blood film schistocytes
ADAMTS13 enzyme absent

Urinalysis:

Protein ++
Blood ++
Leucocytes +
Nitrites -ve
Glucose -ve

What is the most effective treatment for the likely diagnosis?

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?