Archives: MRCP Part 2

MRCP2-2281

A 40-year-old man has been referred to the clinic by his GP due to a 12-month history of night sweats, weight loss, itching, and chronic cough. He reports no significant GI issues but has recently experienced shortness of breath when climbing stairs and has developed an urticarial rash. The following investigations were conducted: eosinophils were 3.0 × 109/l or greater on three occasions in the last year (normal value: 0.04–0.4 × 109/l), creatinine (Cr) was 128 μmol/l (normal value: 50–120 μmol/l), ANCA was negative, CXR showed interstitial infiltrates and small bilateral pleural effusions, echocardiogram (Echo) was suggestive of restrictive cardiomyopathy, and IgE was raised. What is the most likely diagnosis in this case?

MRCP2-2282

A 35-year-old woman presents with a fever of 38.0°C, 90 minutes after starting a red cell transfusion three days post allogeneic bone marrow transplant. Prior to the transfusion, her temperature was 37.6°C. On examination, she appears flushed, breathless, and complains of dizziness and a tight chest. Her heart rate is 110 beats per minute and regular, blood pressure is 90/60 mmHg, and auscultation of the chest reveals widespread wheeze. The staff nurse stops the transfusion and checks a full blood count, which shows abnormal results. The patient’s haemoglobin, white cell count, neutrophils, lymphocytes, monocytes, eosinophils, basophils, and platelet count are all outside of the normal range. What other action should be taken?

MRCP2-2283

A 37-year-old male presents to the emergency department with pain in his left leg, which he attributes to twisting his ankle while playing basketball with his friends approximately 1 week ago. He does not recall any insect bites but has become increasingly concerned as his leg has become more swollen and tender in the calf region.

He has no significant medical history but has been taking ibuprofen for the pain. His only other medication is a daily multivitamin. He consumes alcohol socially at the weekends and smokes approximately 5-10 cigarettes a day. On physical exam he is afebrile and his other vital signs are within normal limits. He is able to ambulate in the emergency department without significant issues, and there are no obvious skin breakages or significant bony deformities. You note that his left leg is significantly swollen compared to the right leg and there is evidence of pitting oedema and erythema. Passive dorsiflexion of his left foot leads to significant pain.

What is the next best step in the management of this patient?

MRCP2-2284

A 50-year-old man has been diagnosed with renal cell carcinoma and is scheduled for a nephrectomy in four days. He presents with a suddenly swollen and tender left calf, and an ultrasound confirms a deep vein thrombosis extending to the femoral vein. What is the most appropriate course of action for management?

MRCP2-2285

You are asked to evaluate a 69-year-old male who is experiencing coffee ground vomiting while on the oncology ward. He has a history of colorectal cancer and is currently undergoing curative chemotherapy.

The patient’s blood results are as follows:

– Hb 95 g/l
– Platelets 34 * 109/l
– WBC 14 * 109/l
– PT ratio 2.4
– aPTT ratio 2.1
– D-dimer 1540 ng/ml (normal < 500)
– Fibrinogen 0.8 g/l (normal 1.5-4.0)

You administer fresh frozen plasma, and the repeat blood results are as follows:

– Hb 91 g/l
– Platelets 24 * 109/l
– WBC 18.4 * 109/l
– PT ratio 2.2
– aPTT ratio 1.9
– Fibrinogen 0.85 g/l (normal 1.5-4.0)

What is the appropriate treatment for this patient?

MRCP2-2286

A 50-year-old woman presents to the Emergency Department with haematemesis. She experienced upper abdominal pain yesterday and began vomiting dark brown material about an hour ago. She also had loose stools today. She recalls having a couple of similar episodes of abdominal pain over the last 2 months but much less severe and not associated with vomiting.

Her medical history includes hypertension, high cholesterol, type 2 diabetes, atrial fibrillation, and chronic back pain. She takes bisoprolol, ramipril, atorvastatin, metformin, sitagliptin, apixaban, paracetamol, and codeine. She also admits to taking some other over-the-counter pain relief for her back in recent months. She took her regular morning medication 10 hours ago but has not had any since.

On examination, her heart rate is 105 beats per minute and blood pressure is 112/88 mmHg. She appears clammy and pale. She is very tender in the epigastric region with guarding and normal bowel sounds. There is malena on rectal examination.

Bloods have been sent but are not yet available, though a haemoglobin on venous gas is 96 g/l.

She is started on fluids and an urgent endoscopy is requested. What medication should be administered to help manage the bleeding?

MRCP2-2287

A 20-year-old man comes to your clinic with a concern about a dusky discolouration that he has had for as long as he can remember. He mentions that none of his relatives have a similar skin colour and that it seems to be getting darker with time. He reports taking oral isotretinoin on-and-off for four years to manage his acne. Upon examination, his chest sounds normal, but his oxygen saturation by pulse oximetry is 91%. An arterial blood gas test reveals a pO2 of 10.6kPa, FO2Hb of 65%, and metHb of 30%.

What treatment would you recommend for this young man?

MRCP2-2288

A 42-year-old woman presents to the clinic with worsening bruising and frequent nose bleeds over the past week. She has a history of rheumatoid arthritis and drinks 70 units of alcohol per week. On examination, she has widespread petechiae and purpura, as well as palpable hepatosplenomegaly. Her blood results show thrombocytopenia, elevated liver enzymes, and prolonged PT and APTT. What is the most likely cause of her thrombocytopenia?

MRCP2-2289

A 68-year-old woman visits her primary care physician complaining of intermittent nosebleeds over the past two days. She has a history of hypertension but is otherwise in good health. During the examination, her blood pressure is 135/86, and her cardiovascular and chest exams are normal. Her abdomen is soft and non-tender, with no masses or enlarged organs. However, she has multiple bruises on her limbs and trunk, as well as a petechial rash on her shins. The physician orders further tests, which reveal a haemoglobin level of 110 g/L (115-165), an MCV of 83 fL (80-96), a white cell count of 26.9 ×109/L (4-11), and platelets of 15 ×109/L (150-400). The blood film shows thrombocytopenia with platelet anisocytosis, numerous mature lymphocytes with high nuclear: cytoplasmic ratio, and numerous smear cells. The manual differential shows neutrophils of 4.3 ×109/L (1.5-7), lymphocytes of 22.0 ×109/L (1.5-4), monocytes of 0.4 ×109/L (0-0.8), eosinophils of 0.1 ×109/L (0.04-0.4), and basophils of 0.1 ×109/L (0-0.1). What would be the next step in managing this patient?

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?