Archives: MRCP Part 2

MRCP2-2314

A 70-year-old man presents to the clinic with a four-month history of abdominal swelling and discomfort along with breathlessness. Upon examination, he appears unwell and pale. The liver is palpable 12 cm below the right costal margin, and the spleen is palpable 15 cm below the left costal margin. No lymphadenopathy is detected. The following investigations were conducted:

Hb 59 g/L (130-180)
RBC 2.1 ×1012/L –
PCV 0.17 l/l –
MCH 30 pg (28-32)
MCV 82 fL (80-96)
Reticulocytes 1.4% (0.5-2.4)
Total WBC 23 ×109/L (4-11)
Normoblasts 8% –
Platelets 280 ×109/L (150-400)
Neutrophils 9.0 ×109/L (1.5-7)
Lymphocytes 5.2 ×109/L (1.5-4)
Monocytes 1.3 ×109/L (0-0.8)
Eosinophils 0.2 ×109/L (0.04-0.4)
Basophils 0.2 ×109/L (0-0.1)
Metamyelocytes 5.1 ×109/L –
Myelocytes 1.6 ×109/L –
Blast cells 0.4 ×109/L –

The blood film shows anisocytosis, poikilocytosis, and occasional erythrocyte tear drop cells. What is the correct term for this blood picture?

MRCP2-2315

A 28-year-old male with Hodgkin’s lymphoma and a bulky mediastinal mass at diagnosis has undergone combination chemotherapy and radiotherapy to the mediastinum. What aspects of his health will require long-term monitoring?

MRCP2-2316

A 65-year-old woman presents to the Emergency Department with increasing confusion and headaches, along with multiple bruises on her shins and arms. She has a temperature of 38 °C and a petechial rash over her chest. On examination, she has bronchial breathing at the right base and 1-cm palpable hepatosplenomegaly. Her blood tests reveal a haemoglobin level of 55 g/l, a white cell count of 18 × 109/l, and a platelet count of 20 × 109/l, among other abnormalities. She is started on treatment for suspected acute promyelocytic leukaemia (APL) and concurrent pneumonia, but three days into her admission, she develops a fever and progressive shortness of breath. What is the best course of action, given the likely diagnosis?

MRCP2-2317

A 56-year-old man presents to the Emergency Department (ED) with increasing peripheral oedema and shortness of breath. He has severe exercise intolerance and struggles to move around his home.
Upon examination, signs of chronic liver disease (CLD) and biventricular cardiac failure are present. His blood pressure (BP) is 112/68 mmHg, with a pulse of 83 beats per minute (bpm). The diagnosis is cardiomyopathy, and he admits to being unable to reduce his alcohol consumption.
What factor will have the greatest impact on his prognosis?

MRCP2-2318

A 54-year-old man with chronic renal failure visited the renal clinic. He was receiving regular haemodialysis and had been taking oral ferrous sulphate (200 mg three times a day) for the past six months. During his clinic visit, his haemoglobin level was found to be 76 g/L, which was significantly lower than the 106 g/L level recorded six months ago. What is the best course of treatment in this case?

MRCP2-2301

You are asked to review a 76-year-old woman on the oncology ward. She complains of widespread bruising and bleeding gums. She has a past medical history of lymphoma. She has required 7 red cell transfusions and 4 platelet transfusions in the past 12 months.

Blood results are as follows:

Hb 98 g/l
Platelets 6 * 109/l
WBC 3.9 * 109/l

You decide to transfuse her 1 unit of platelets. A repeat blood test the following day is reported below:

Hb 94 g/l
Platelets 10 * 109/l
WBC 4.1 * 109/l

What investigation will you order next?

MRCP2-2302

A 65-year-old Chinese man has been prescribed quinine by his GP for leg cramps. After a week, he visits the hospital complaining of darkened urine for five days and increasing breathlessness, back pain, and fatigue for two days. Upon investigation, his haemoglobin level is found to be 70 g/L (130-180) and his reticulocyte count is elevated. What is the most likely cause of this adverse drug reaction?

MRCP2-2303

A 54-year-old woman was undergoing treatment for non-Hodgkin’s lymphoma. She had completed three cycles of chemotherapy without any issues and was now preparing for the fourth cycle. However, she began to experience a tingling sensation in her hands and feet, which gradually worsened and was accompanied by numbness.

The patient had a history of hypertension and was taking atenolol, as well as omeprazole for a previous duodenal ulcer, allopurinol as prophylaxis against tumor lysis, ciprofloxacin and co-trimoxazole as antibacterial prophylaxis, and itraconazole as anti-fungal prophylaxis. She had no history of diabetes mellitus in herself or her family.

Upon examination, the patient exhibited diminished sensation in a glove and stocking distribution, indicative of peripheral neuropathy. Her blood pressure was 150/85 mmHg, and a random blood glucose test revealed a level of 11 mmol/L. The most likely cause of her symptoms was vincristine, which was part of her chemotherapy regimen.

Which of the patient’s medications could potentially worsen the neurotoxicity caused by vincristine?

MRCP2-2304

A 65-year-old man has recently undergone successful mitral valve replacement for rheumatic valvular heart disease. He has been started on warfarin and his INR has been stabilised with a plan to maintain it within the range of 2.5-3.5. However, he now presents to his general practitioner with complaints of recurrent episodes of dysuria and frequency, for which he has been prescribed co-trimoxazole. What steps should be taken to ensure that his INR remains within the target range?

MRCP2-2305

A 47-year-old male presented for pre-operative assessment prior to a routine laparoscopic cholecystectomy. He had a history of a previous surgery for a broken leg. His only medication was for high blood pressure. He reported occasional right upper quadrant pain due to gallstones but was otherwise healthy. The following routine blood tests were obtained:

Haemoglobin: 140 g/L (115 – 165)
White cell count: 8.2 ×109/L (4 – 11)
Neutrophils: 5.5 ×109/L (1.5 – 7)
Lymphocytes: 1.8 ×109/L (1.5 – 4)
Monocytes: 0.3 ×109/L (0 – 0.8)
Eosinophils: 0.2 ×109/L (0.04 – 0.4)
Basophils: 0.1 ×109/L (0 – 0.1)
Platelet count: 230 ×109/L (150 – 400)
Prothrombin time: 12.8 s (11.5 – 15.5)
APTT: 78 s (30 – 40)
Fibrinogen: 4.8 g/L (1.8 – 5.4)
APTT (50:50 mix with normal plasma): 72 s

The laparoscopic cholecystectomy was performed without any complications. What is the most likely interpretation of these laboratory results?