Archives: MRCP Part 2

MRCP2-4546

A 28-year-old microbiologist presents with persistent fevers of >39°C, severe joint pains, and swelling of the hands and feet.

She complains of a pale pink macular rash, which she thinks may be secondary to the antibiotic her GP prescribed for fever.

On examination, you find a palpable splenic tip and a single lymph node in the posterior cervical region.

Blood tests are as follows:

Haemoglobin 113 g/L (100-160)

Sodium 136 mmol/L (133-146)

ESR 110 mm/hr (0-9)

White Cell Count 11.3 ×109/L (3.5-10.9)

Potassium 4.0 mmol/L (3.5-5.3)

CRP 322 mg/L (<5) Neutrophils 9.0 ×109/L (1.9-9.0) Creatinine 83 µmol/L (44-80) Platelets 495 ×109/L (150-450) Urea 5.0 mmol/L (2.5-7.8) Ferritin >3000 µg/L (13-300)

RF Negative

ANA Negative

Serum electrophoresis Normal

HIV Negative

EBV serology Negative

Blood film Normal

TFTs Normal

What is the most likely diagnosis for this 28-year-old microbiologist?

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?

MRCP2-4556

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?

MRCP2-4550

A 54-year-old man presents with lethargy and reduced sensation in both feet. He reports a 2 month history of fevers and 5kg weight loss. He also reports intermittent testicular pain.

On examination there is livedo reticularis on both legs and reduced light touch and pain sensation on both feet.

Blood tests reveal:

Hb 116 g/l Na 137 # mmol/l Bilirubin 18 µmol/l
Platelets 487 * 109/l K+ 4.8 mmol/l ALP 92 u/l
WBC 8.3 * 109/l Urea 12.8 mmol/l ALT 102 u/l
Neuts 6.3 * 109/l Creatinine 182 µmol/l γGT 16 u/l
MCV 89 fL ESR 78mm/hr Albumin 34 g/l

Which investigation is most likely to reveal the diagnosis?

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?

MRCP2-4535

A 85-year-old female presents to the emergency department with a four-day history of increasing shortness of breath and worsening of a chronic productive cough. She does not speak English, but her medical records indicate that she recently moved from rural India to live with her family two years ago. There is no known underlying lung condition. Upon examination, bilateral expiratory wheeze and hyperexpanded lungs are observed, with no clear inspiratory crackles. Heart sounds appear normal, and mild bilateral pitting edema is present. Her saturation measures 88% on air via pulse oximeter, and her respiratory rate is 24 to 28 per minute. A chest radiograph shows hyperexpanded lungs with mild bibasal fibrotic changes but no focal signs of consolidation. She has no history of smoking or alcohol use. Her blood tests reveal:

– Hb 15.0 g/dl
– Platelets 211 * 109/l
– WBC 11.4 * 109/l
– Neutrophils 9.5 * 109/l
– Urea 8.4 mmol/l
– Creatinine 112 µmol/l
– CRP 37 mg/l

What is the most likely diagnosis?

MRCP2-4536

A 31-year-old man presents with a history of recurrent ulcers over several months. He reports experiencing oral ulcers regularly, with multiple occurring at a time, which typically resolve within a week. Additionally, he has been experiencing painless genital ulcers. He has recently attended the eye casualty department twice, where he was diagnosed with uveitis. On examination today, he has several oral ulcers and genital ulcers. What findings would support the probable diagnosis?

MRCP2-4545

A 63-year-old man presents with a week of right-sided shoulder pain. He denies any trauma and denies radiation of the pain. There is no associated weakness or numbness. The pain is more noticeable at the extremities of movement and is affecting activities of daily living. His past medical history includes type 2 diabetes mellitus and asthma.

Upon examination, the affected shoulder is painful and restricted, with both active and passive movement. External rotation is most severely limited. Pain is elicited when applying direct pressure to the coracoid process.

What is the most appropriate next step given the most likely diagnosis?

MRCP2-4537

A 55-year-old man of Afro-Caribbean descent presents to the clinic with complaints of fever, joint pain, and lethargy. He has also noticed a rash on his arms and neck that comes and goes over the past six months. He has a medical history of congestive heart failure and chronic kidney disease due to hypertension. His current medications include bisoprolol, aspirin, and hydralazine/isosorbide dinitrate. On examination, there is no joint swelling, but he has patches of scaling on his neck and forearms. Laboratory tests reveal positive rheumatoid factor, anti-nuclear antibody, anti-single stranded DNA, and anti-histone antibodies, but negative anti-extractable nuclear antigen. What is the most likely diagnosis?

MRCP2-4538

A 75-year-old male presents to the Emergency Department with a two-day history of right temporal, throbbing headache, constant in nature and 8/10 severity. He reports this being the first ever episode of this headache and is different to his previous migraines, which have been typically in the left occipital region, lasting minutes, and fairly stereotyped over the past 50 years. Apart from migraines, he has no other medical history.

On examination, his right scalp is tender and a prominent right temporal artery is noted. He is apyrexic with no skin rashes. His blood tests are as follows:

Hb 140 g/l
Platelets 550 * 109/l
WBC 11.0 * 109/l
ESR 80 mm/hr

Na+ 145 mmol/l
K+ 4.5 mmol/l
Urea 9.8 mmol/l
Creatinine 110 µmol/l
CRP 25 mg/l

You empirically start him on 60mg prednisolone. He undergoes temporal artery biopsy within 24 hours of his admission demonstrating no signs of temporal arteritis.

What is the most appropriate next step?