Archives: MRCP Part 2

MRCP2-2340

A 63-year-old man has been regularly visiting the haematology clinic every six months. During his latest appointment, he complained of a headache, blurred vision, aching bones, and extreme lethargy. His wife reported that he has been very vague at times over the past four weeks and drowsy when he was awake.

Upon examination, he appeared pale with a blood pressure of 125/65 mmHg. He was afebrile, and his respiratory rate was 12 breaths per minute. Cardiovascular, chest, and abdominal examination were unremarkable.

Further investigations revealed a haemoglobin level of 82 g/L (130-180), MCV of 88 fL (80-96), white cell count of 9.0 ×109/L (4-11), and a monoclonal band (IgA kappa) with immune paresis. The IgA kappa level was 76 g/L.

Which of the following treatment options would be best for this patient?

MRCP2-2341

A 65 year-old woman presents with worsening back pain over the past month, despite never experiencing it before. She has been feeling lethargic and her husband has noticed occasional confusion. She also reports long-standing exertional breathlessness and constipation, but no bowel or bladder issues.

Her medical history includes chronic obstructive pulmonary disease, which is being managed by her GP, and quitting smoking two years ago. Her last well woman check up was normal, except for slightly elevated cholesterol that she is managing with diet.

During examination, she walks normally and has mild tenderness over the L3/L4 vertebra with no neurological deficits in her lower limbs. Cardiorespiratory examination reveals an ejection systolic murmur and a normal second heart sound.

Lab results show low hemoglobin, normal bilirubin, elevated platelets, high potassium, elevated ALP, normal ALT, high creatinine, and high corrected calcium. Her ESR is also elevated.

What is the most likely diagnosis?

MRCP2-2342

A 29-year-old teacher was referred to the hospital by her general practitioner. She had presented seven days ago with a three day history of malaise, headache, and myalgia and subsequently developed a dry cough and fever. Her GP had prescribed amoxicillin/clavulanic acid, but the symptoms failed to resolve. On the day of referral, the patient continued to complain of cough and had become mildly dyspnoeic; she also complained of a global headache, myalgia and arthralgia.

During the examination, she appeared unwell and was febrile (39°C). A maculopapular rash was evident over her upper body. Heart sounds were normal; BP 120/70 mmHg. On auscultation of her chest, fine crackles were audible in the left mid-zone. Mild neck stiffness was noted.

The following investigations were conducted:
– Hb 84 g/L (130-180)
– WBC 8 ×109/L (4-11)
– Platelets 210 ×109/L (150-400)
– Reticulocytes 8% (0.5-2.4)
– Na 129 mmol/L (137-144)
– K 4.2 mmol/L (3.5-4.9)
– Urea 5.0 mmol/L (2.5-7.5)
– Creatinine 110 µmol/L (60-110)
– Bilirubin 19 µmol/L (1-22)
– Alk phos 130 U/L (45-105)
– AST 54 U/L (1-31)
– GGT 48 U/L (<50) The chest x-ray showed patchy consolidation in both mid-zones. What investigation should be performed to confirm the cause of her abnormal blood count?

MRCP2-2343

A 65-year-old man with a history of myelodysplasia visits a haematology clinic complaining of rapid weight loss, increased nosebleeds, and more pronounced fatigue than before. He has the single lineage dysplasia subtype and typically requires monthly transfusions. He presents two weeks after his last red blood cell top-up.

Upon examination, his blood results reveal the following:

– Hb 66 g/L (normal range for males: 135-180; females: 115-160)
– Platelets 9 * 109/L (normal range: 150-400)
– WBC 1.1 * 109/L (normal range: 4.0-11.0)

As a result, he is admitted for blood and platelet transfusions, and a blood film is ordered. What is the expected outcome of the blood film analysis?

MRCP2-2344

A 70-year-old man presents to the clinic with a four-month history of breathlessness, abdominal swelling, and discomfort. Upon examination, he appears pale and unwell, with a palpable liver and spleen. Laboratory investigations reveal abnormal blood counts and a blood film showing anisocytosis, poikilocytosis, and occasional erythrocyte tear drop cells. What is the initial diagnostic test of choice?

MRCP2-2345

An 80-year-old man presents to haematology with complaints of fatigue and weight loss. Despite undergoing upper and lower GI endoscopy, which showed no abnormalities, he has been referred for further investigation of anaemia. The following blood film was obtained:

What is the probable diagnosis?

MRCP2-2346

A 65-year-old man complains of weakness in his left leg that he first noticed a couple of weeks ago. Upon examination, you observe weakness in left ankle plantar flexion. The nerve conduction studies of the tibial nerve reveal a conduction velocity of 25 metres per second (normal >50) and an amplitude of 21mV (normal >17). What is the probable cause of this weakness?

MRCP2-2347

You are asked to counsel a middle-aged couple expecting a grandchild. They are both in good health, with no previous medical history. They both come from South East Asia, and there is no family history of birth abnormalities. Physical examination shows no abnormalities. The following investigations were done:

MALE

Haemoglobin (Hb) 117 g/l 135–175 g/l
Mean corpuscular volume (MCV) 70 fl 76–98 fl
Mean cell haemoglobin (MCHb) 19 pg 27–32 pg
Red cell count 5.6 × 1012/l 4.7–6.9 × 1012/l
Haemoglobin electrophoresis normal

FEMALE

Haemoglobin (Hb) 101 g/l 115–155 g/l
Mean corpuscular volume (MCV) 68 fl 76–98 fl
Mean cell haemoglobin (MCHb) 18 pg 27–32 pg
Red cell count 6.0 × 1012/l 4.7–6.9 × 1012/l
Haemoglobin electrophoresis normal

What is the potential risk for the fetus to develop a certain condition?

MRCP2-2330

A 27-year-old woman presented at 35 weeks of pregnancy with profuse vaginal bleeding. She had suffered two previous miscarriages.

She had a pulse of 95 beats per minute, blood pressure of 110/84 mmHg and no fetal heart sounds were audible.

Investigations revealed:

Haemoglobin 98 g/L (115 – 165)

Platelets 66 ×109/L (150 – 400)

Prothrombin time 21 sec (11.5-15.5)

APTT 52 sec (30-40)

Fibrinogen 0.5 g/L (2-4)

What is the most appropriate next step in management?

MRCP2-2331

A 12-year-old girl returns from a trip to Africa with her family and is found to have jaundice. She had been taking antimalarial medication as a prophylaxis. Upon examination, her complete blood count reveals a hemoglobin level of 80 g/L, and her blood film shows the presence of Heinz bodies and blister cells. What disorder is associated with these findings?