Archives: MRCP Part 2

MRCP2-2292

A 79-year-old man presents with a 9-month history of 7 kg of weight loss, fevers, and night sweats. During examination, he has cervical and inguinal lymphadenopathy and a slightly enlarged spleen. The following are his blood results:

– Hb 98 g/L Male: (135-180) Female: (115 – 160)
– Platelets 145 * 109/L (150 – 400)
– WBC 38.5 * 109/L (4.0 – 11.0)
– Neuts 2.6 * 109/L (2.0 – 7.0)
– Lymphs 32 * 109/L (1.0 – 3.5)

What would be the preferred diagnostic investigation for the most probable diagnosis?

MRCP2-2293

A 16-year-old male patient presents to the emergency department with complaints of difficulty breathing. He has no history of taking any medications, including recreational, herbal, or over-the-counter drugs. He also denies any exposure to local anesthetics or chemicals. Upon examination, the patient appears cyanotic, but his chest is clear on auscultation. Despite the cyanosis, his SpO2 level is 92%.

The patient is started on 15 L O2 via a non-rebreather mask. Blood gas analysis reveals the following results:

– pH: 7.28 (normal range: 7.35 – 7.45)
– PaO2: 66.5 kPa (normal range: 10.3 – 13.3 kPa)
– PaCO2: 2.8 kPa (normal range: 4.7 – 6 kPa)
– HCO3: 22 mmol/L (normal range: 22 – 28 mmol/L)
– SaO2: 52% (normal range: 94-98)

The patient moved to the UK from India six weeks ago, and his medical records are not available. However, he informs you that his family has a history of a blood disorder.

Based on the most likely diagnosis, what is the recommended treatment?

MRCP2-2294

A 50-year-old woman with chronic renal failure due to systemic lupus erythematosus is being seen in a low clearance clinic for routine follow-up. She has been experiencing joint discomfort and has been taking naproxen as needed, along with prednisolone 2.5 mg once daily and azathioprine 50 mg once daily for disease control. Her renal function is stable, with a creatinine level of 300 mmol/L and a creatinine clearance of 18 ml/min. She also has controlled secondary hyperparathyroidism. Despite being on oral ferrous sulphate 200 mg three times daily for three months, she has been anemic for the past six months. An investigation of dyspepsia with an OGD showed only mild gastritis. Her laboratory results show a hemoglobin level of 94 g/L (normal range: 115-165), 12% hypochromic red cells, platelets of 180 ×109/L (normal range: 150-400), white cell count of 6.4 ×109/L (normal range: 4-11), serum folate of 4.0 ug/L (normal range: 2-11), serum ferritin of 230 ug/L (normal range: 15-300), and transferrin saturation of 17%. What treatment options should be considered at this point?

MRCP2-2295

A 50-year-old African American woman comes to the clinic with a platelet count of 511 ×109/L. Her blood picture shows microcytic hypochromia and a haemoglobin level of 102 g/L. What is the most crucial test to perform next?

MRCP2-2296

A 73-year-old woman comes to the emergency department complaining of a swollen and painful leg that has developed over two days. She feels otherwise healthy. She recently returned from a trip to Spain four weeks ago. She can move around on her own and has not experienced any periods of reduced mobility. She has a history of breast cancer that was diagnosed four years ago and has since spread to her liver. She is currently undergoing hormonal treatment.

During the examination, her left leg appears red and swollen, with a significantly larger calf diameter on the left side. A doppler ultrasound scan reveals a deep vein thrombus on the left side. What is the most appropriate anticoagulation strategy?

MRCP2-2297

A 20-year-old man with hereditary spherocytosis presents to the clinic with complaints of chronic fatigue and persistent left upper quadrant pain and discomfort. He had been hospitalized 8 months ago for an acute haemolytic crisis due to parvovirus infection. On examination, splenomegaly is confirmed. Further investigations reveal a solitary gallstone in the gallbladder and anemia with elevated MCV.

What is the best course of action for this patient?

MRCP2-2298

A 45-year-old man with acute pancreatitis is admitted to the surgical ward. During his hospital stay, he experiences recurrent epistaxis, gingival bleeding, and haematuria. Upon re-examination, multiple petechiae are observed, and he displays mild confusion. His observations reveal some hypotension.

The following blood tests are conducted:

Platelets 83 * 109/L (150 – 400)
Prothrombin time (PT) 26 secs (10-14 secs)
Activated partial thromboplastin time (APTT) 48 secs (25-35 secs)
Fibrinogen 0.3 g/L (2 – 4)

Apart from general resuscitation, what is the most useful first-line treatment?

MRCP2-2299

A 76-year-old man presents to the acute medical unit with a 4-day history of lower limb weakness. He has a 7-month history of progressive back pain. He denies any bowel or bladder dysfunction, and saddle anaesthesia.

Blood results are as follows:

Hb 112 g/L Male: (135-180)
Female: (115 – 160)
Platelets 178 * 109/L (150 – 400)
WBC 7.2 * 109/L (4.0 – 11.0)
Na+ 136 mmol/L (135 – 145)
K+ 5.2 mmol/L (3.5 – 5.0)
Urea 15.8 mmol/L (2.0 – 7.0)
Creatinine 290 µmol/L (55 – 120)

Paraprotein No paraprotein detected
Kappa free light chains 12,200 mg/L (3.3 – 19.4)
Lambda free light chains 130 mg/L (5.7 – 26.3)
Kappa to Lambda ratio 93.8 (0.26 – 1.65)

An MRI spine confirms cauda equina syndrome due to a large paravertebral soft tissue mass. In addition, there is widespread abnormal marrow involvement throughout the spine.

What is the most likely diagnosis?

MRCP2-2300

A 67-year-old woman is admitted to the hospital with headaches and visual disturbances. The patient has a history of multiple myeloma. During her stay, she experiences a persistent nosebleed that is difficult to control. Fundoscopy reveals dilated retinal veins and retinal hemorrhage in her left eye. She appears pale and short of breath, with a blood pressure of 120/70 mmHg, a heart rate of 110 bpm, and a temperature of 38 °C. The on-call ENT surgeon is consulted to pack her nose. After receiving plasmapheresis, she makes a good recovery. Her blood tests one week later show:

Hemoglobin (Hb) 95 g/l 120–160 g/l
Platelets (PLT) 100 × 109/l 150–400 × 109/l
Mean corpuscular volume (MCV) 98 fl 80–100 fl
Reticulocytes 120 × 109/l 25–85 × 109/l
Lactate dehydrogenase (LDH) 800 IU/l 140–280 IU/l
Immunoglobulin G (IgG) 50 g/l 6–16 g/l
Beta-2 microglobulin 8 mg/l 1.3–2.9 mg/l
Albumin 30 g/l 35–55 g/l

Which of the following factors in this patient’s case contributes to a worse prognosis?

MRCP2-2290

A 16-year-old girl presents to the clinic with a concerning issue. She has been experiencing spontaneous bruising for the past two days and has no prior medical history or regular medication use. The bruises have appeared on her hips, thighs, and upper arms without any trauma to account for them. The largest bruise measures 15 cm in diameter. Although she recently had a mild viral illness, she currently feels well. Upon investigation, her haemoglobin levels are within normal range at 141 g/L (115-165), but her white blood cell count is 7.3 ×109/L (4-11) and platelet count is only 15 ×109/L (150-400). What is the most crucial next step in her care?