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?

MRCP2-2270

A 19-year-old female patient visits the haematology clinic with complaints of spontaneous bruising, heavy menstrual bleeding, and recurrent nosebleeds. She has been experiencing these symptoms continuously since her teenage years, but recently received an iron transfusion due to anaemia which prompted further investigation.

During the examination, the patient appears alert and in good health. Multiple purpura are observed on both arms, and the patient denies any trauma or itchiness.

The following test results were obtained:
– Hb: 98 g/l
– Platelets: 314 * 109/l
– WBC: 5.6 * 109/l
– PT: 13.8
– APTT: 34.3
– PFA-100 assay: prolonged closure time
– Flow cytometry: GPIIb/IIIa negative
– Ristocetin-induced platelet aggregation: normal agglutination

What is the most likely diagnosis for this patient?

MRCP2-2271

A 35-year-old male presents with a rash and low-grade fever (37.6°C) three weeks after receiving an allogeneic bone marrow transplant for high-risk acute myeloid leukemia in first complete remission. Initially, the rash is maculopapular and affects his palms and soles. However, after 24 hours, general erythroderma is noted on his trunk and limbs. Although his total bilirubin was previously normal, it is now 40 µmol/L (1-22). Despite these symptoms, he remains in good health. What would be the appropriate management for this patient at this stage?

MRCP2-2272

A 50-year-old woman is being evaluated before undergoing a hysterectomy and oophorectomy. She has no family history of bleeding or thrombosis, and has not experienced any post-traumatic or post-surgical bleeding (although she has had an appendicectomy and tonsillectomy in the past). Additionally, she is not taking any anti-thrombotic or anticoagulant medication. What is the appropriate method for assessing her risk of bleeding prior to surgery?

MRCP2-2273

Is there a current trend of excessive thrombophilia testing in various situations where it has been proven unnecessary?
At what age should clinicians consider screening for thrombophilia in specific clinical scenarios?