Archives: MRCP Part 2

MRCP2-2261

A 67-year-old man has been admitted with worsening abdominal pain, hypotension and altered mental state. He is currently being treated for intra-abdominal sepsis secondary to peritoneal dialysis for chronic renal failure due to diabetic nephropathy. Previous medical history includes type 2 diabetes mellitus, angina, hypertension, hyperlipidaemia, and diabetic retinopathy. The patient is not anti-coagulated but does take aspirin.

Intravenous antibiotics and fluid are initiated for the patient.

The following are the patient’s results:

Hb 91 g/L Male: (135-180)
Female: (115 – 160)
Platelets 60 * 109/L (150 – 400)
WBC 24.5 * 109/L (4.0 – 11.0)
Na+ 128 mmol/L (135 – 145)
K+ 5.8 mmol/L (3.5 – 5.0)
Urea 31.7 mmol/L (2.0 – 7.0)
Creatinine 645 µmol/L (55 – 120)
CRP 317 mg/L (< 5)
PT 22 seconds (10-14 seconds)
APTT 56 seconds (30-40 seconds)

The patient undergoes a CT scan which reveals a spontaneous retroperitoneal haemorrhage and is referred to interventional radiology.

What type of blood product is required based on the patient’s coagulation profile?

MRCP2-2262

A 25-year-old male is admitted to hospital after his GP identified a pancytopenia following a workup for recent fatigue and weight loss. An hour after arrival he develops a sustained nosebleed. On review, you notice oozing from his cannula sites and non-blanching purpura over his arms and legs.

What could be the probable reason for this patient’s condition?

MRCP2-2263

A 65-year-old woman comes to the clinic complaining of fatigue, weight loss, and a tingling sensation in her hands and feet. She is also experiencing frequent headaches. Her medical history includes hypertension and osteoporosis. Upon examination, there is lymphadenopathy and hepatosplenomegaly. The following results were obtained from her tests:

Haemoglobin (Hb): 100 g/l (normal MCV) 135–175 g/l
White cell count (WCC): 3.8 × 109/l 4.0–11.0 × 109/l
Platelets (PLT): 80 × 109/l 150–400 × 109/l
Sodium (Na+): 142 mmol/l 135–145 mmol/l
Potassium (K+): 4.9 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr): 140 µmol/l 50–120 µmol/l
Erythrocyte sedimentation rate (ESR): 80 mm/hour < 10mm/hour
Immunoglobulin M (IgM): Paraprotein band
Bone marrow: Plasma cell infiltration

What is the most likely diagnosis for this patient?

MRCP2-2264

A 65-year-old woman with a medical history of diabetes mellitus, essential hypertension, and ischaemic heart disease with a previous myocardial infarction presents with a platelet count of 700 × 109/L (150-400). A bone marrow biopsy reveals an increase in megakaryocytes with lobulated nuclei and abnormal localization, and a positive JAK-2 mutation is detected. What is the appropriate course of action for managing essential thrombocythemia in this patient?

MRCP2-2265

A 29-year-old Afro-Caribbean male presents with a sudden onset of left-sided weakness that has been ongoing for two hours. He denies any sensory involvement, dysarthria, or dysphasia. The patient has a history of sickle cell disease and has experienced two previous episodes of transient ischemic attacks and an acute chest syndrome attack ten days ago. On examination, the patient displays 1/5 power in his left arm, 2/5 in his left leg, and 5/5 in his right side. He reports no sensory disturbances, and his plantar responses are downgoing bilaterally. The patient is unable to perform finger-nose testing. He denies any illicit drug use, is a non-smoker, and does not drink alcohol. The patient has no other past medical history. A hyperacute CT head reveals an area of acute ischemia in the right internal capsule region. What is the most appropriate immediate treatment?

MRCP2-2266

A 55-year-old man presents with the following blood results: haemoglobin 53 g/L (130-180), WBC 250 ×109/L (4-11), and platelet count 25 ×109/L (150-400). He is diagnosed with acute myeloid leukaemia and started on chemotherapy with daunorubicin and cytarabine. On day five, he develops a fever of 39°C, tachycardia of 130 bpm, and blood pressure of 80/45 mmHg. What is the most appropriate treatment for his condition?

MRCP2-2267

A 30-year-old female is involved in a car accident and sustains multiple injuries including fractures of her pelvis, right femur, and left humerus. She undergoes surgery immediately, but experiences life-threatening bleeding during and after the procedure. In total, she receives 24 units of red cells, 6 units of platelets, and 16 units of fresh frozen plasma. Her recovery is difficult, with complications both in the ICU and on the general ward.

Five days after surgery, you are called to see the patient. She is currently receiving a blood transfusion and has developed a fever 45 minutes after starting a unit of red cells. Her temperature is 38.2°C, blood pressure is 110/70 mmHg, and heart rate is 98 bpm. The transfusion is stopped and the patient’s identity and the unit of blood are checked, but everything appears to be correct. The hospital’s transfusion team initiates an investigation into the reaction, and the patient is closely monitored. Fortunately, she remains stable over the next 24 hours and her temperature returns to normal soon after stopping the transfusion.

Further investigation reveals that the patient is blood group A rhesus D negative, and the unit of blood being transfused during the reaction was the correct group and cross match compatible. However, it is discovered that the patient received 2 units of rhesus D positive platelets during her emergency surgery and subsequent bleeding.

What course of action do you recommend at this point?

MRCP2-2268

A 67-year-old male has been diagnosed with chronic lymphocytic leukemia. Before beginning chemotherapy with fludarabine, what antimicrobial prophylaxis should be administered?

MRCP2-2269

As a haematologist, you have been referred a 71-year-old man by the general surgeons. He has been experiencing weight loss and a change in bowel habit for the past two months. A CT scan showed mesenteric lymphadenopathy, with the largest lymph node measuring 4 cm in diameter. The biopsy report of the lymph node reveals a lack of mantle zone and a predominant population of centrocytes with few tangible body macrophages. Immunohistochemistry confirms strong positivity for CD20, CD70a, CD10, BCL2, and BCL6. The proliferation index (Ki-67) is low, no more than 20%. What is the most likely diagnosis?

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?