Archives: MRCP Part 2

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?

MRCP2-2291

A 42-year-old man has been diagnosed with myeloma and started on a treatment regimen of dexamethasone and lenalidomide, which belongs to the same class of drugs as thalidomide. What is the crucial treatment-related matter that needs to be discussed and accurately recorded in the medical records?

MRCP2-2257

A 55-year-old man presented to his GP with complaints of feeling lethargic and unwell. Despite having a normal appetite, he had lost two stones in weight over the past six weeks. He also reported excessive sweating at night, causing his wife to frequently change the sheets. Additionally, he experienced upper abdominal discomfort.

During examination, the patient appeared thin and unwell. His pulse was 90 beats per minute in sinus rhythm with blood pressure of 145/80 mmHg. A short systolic murmur was audible at the lower left sternal edge. His chest was clear, and his abdomen was soft with slight tenderness in the epigastrium and central abdomen. The spleen was palpable 7 cm below the left costal margin.

Further investigations revealed a haemoglobin level of 97 g/L (130-180), a white cell count of 17.4 ×109/L (4-11), and a platelet count of 550 ×109/L (150-400). The blood film showed left-shifted neutrophils with numerous myelocytes present, occasional promyelocytes, and no blasts. There were also a number of nucleated red blood cells as well as a large number of tear drop red cells.

Given these findings, what should be the next investigation performed?

MRCP2-2258

A 22-year-old woman was brought to the Emergency department at 2 am after collapsing at a nightclub. Her friend, who accompanied her, reported that she had been feeling fine earlier in the evening and had been dancing for hours. The patient was known to occasionally drink alcohol, but her friend did not know if she had taken any drugs.

Investigations revealed:

– Haemoglobin 92 g/L (130 – 180)
– White cell count 20.0 ×109/L (4 – 11)
– Neutrophils 18.5 ×109/L (1.5 – 7.0)
– Lymphocytes 1.5 ×109/L (1.5 – 4.0)
– Monocytes 0.6 ×109/L (0 – 0.8)
– Eosinophils 0.3 ×109/L (0.04 – 0.4)
– Basophils 0.1 ×109/L (0 – 0.1)
– Platelets 30 ×109/L (150 – 400)
– Reticulocyte count 8%
– Prothrombin time 30 secs (11.5 – 15.5)
– Activated partial thromboplastin time 80 secs (30 – 40)
– Fibrinogen 0.4 g/L (1.8 – 5.4)
– D-Dimer screen 2.3 mg/L (<0.5)
– Serum sodium 138 mmol/L (137 – 144)
– Serum potassium 5.9 mmol/L (3.5 – 4.9)
– Serum urea 16.0 mmol/L (2.5 – 7.5)
– Serum creatinine 190 µmol/L (60 – 110)
– Lactate dehydrogenase 500 U/L (10 – 250)

A blood film showed red cell fragmentation with polychromasia, toxic granulation of neutrophils, and platelet anisocytosis.

What is the likely diagnosis?

MRCP2-2259

A 38-year-old man is currently undergoing chemotherapy for malignant melanoma which has become disseminated, with spread to his lungs and liver. He has been stable with respect to symptoms over the past few weeks and is expecting to begin the next cycle of chemotherapy in seven days’ time. He is very concerned because he suffered a minor knee sprain slipping on some steps but now has a very large left knee haematoma.
Investigations:
Investigations Results Normal Values
Haemoglobin (Hb) 112 g/l 135–175 g/l
White cell count (WCC) 9.1 × 109/l 4–11 × 109/l
Platelets (PLT) 152 × 109/l 150–400 × 109/l
Sodium (Na+) 137 mmol/l 135–145 mmol/l
Potassium (K+) 4.3 mmol/l 3.5–5.0 mmol/l
Creatinine 110 µmol/l 50–120 µmol/l
Alanine aminotransferase (ALT) 112 U/l 5–30 IU/l
Alkaline phosphatase (ALP) 187 U/l 30–130 IU/l
Bilirubin 13 µmol/l < 17 µmol/l
Prothrombin time (PT) 12.3 s 10.6–14.9 s
Activated partial thromboplastin time (APTT) 54.2 s 22–41 s
Which of the following is the most likely diagnosis?

MRCP2-2260

A 56-year-old man is admitted to the hospital with a diagnosis of urosepsis. After 24 hours, he develops multiple bruises on his abdomen, arms, and legs, and there is bleeding from his cannula site. The following are his blood test results:

– Hb: 110 x1012/L (normal range: 130-168 x1012/L)
– WCC: 19 x109/L (normal range: 4.2-10.6 x109/L)
– Platelets: 50 x109/L (normal range: 130-370 x109/L)
– CRP: 300 mg/L (normal range: 0-5 mg/L)
– Fibrinogen: 3.8 g/L (normal range: 1.8-4.0 g/L)
– PT: 20s (normal range: 9-12s)
– APTT: 38s (normal range: 23-31s)
– Creatinine: 150μmol/L (normal range: 60-125 μmol/L)
– eGFR: 60 mL/min/1.73 m2 (normal range: >90 mL/min/1.73 m2)

What is the most likely cause of his symptoms?