Archives: MRCP Part 2

MRCP2-2246

A 72-year-old man presents with fatigue and pain in his lower back and left femur. He is currently undergoing investigations for anemia and is scheduled for an upper GI endoscopy. Upon examination, the following results were obtained: hemoglobin (Hb) level of 89 g/l (normal range: 135-175 g/l), viscosity of 2.5 (normal range: 1.5-1.72), creatinine (Cr) level of 210 μmol/l (normal range: 50-120 mol/l), negative fecal occult blood test, and a prostate-specific antigen (PSA) level of 4. X-ray of the left femur revealed multiple osteolytic lesions. What is the most likely underlying diagnosis?

MRCP2-2247

A 50-year-old man visited the clinic after being referred by his GP. He reported feeling tired and had lost 10 kg in weight. He also experienced excessive sweating, particularly at night, and had some discomfort in his upper abdomen. During the examination, the doctor palpated his spleen 12 cm below the left costal margin.

The following investigations were conducted:
– Haemoglobin: 97 g/L (130-180)
– White cell count: 17.4 ×109/L (4-11)
– Neutrophils: 14.0 ×109/L (1.5-7)
– Lymphocytes: 1.5 ×109/L (1.5-4)
– Monocytes: 0.8 ×109/L (0-0.8)
– Basophils: 0.7 ×109/L (0-0.1)
– Eosinohils: 0.4 ×109/L (0.04-0.4)
– Platelets: 550 ×109/L (150-400)

The blood film showed left-shifted neutrophils with numerous myelocytes present. There were occasional promyelocytes but no blasts. Additionally, there were several nucleated red blood cells and platelet anisocytosis with thrombocytosis.

What further investigation should be conducted?

MRCP2-2248

A 26-year-old male presents with severe fatigue. Upon examination, his full blood count reveals a haemoglobin level of 45 g/L (130-180), neutrophils at 0.7 ×109/L (1.5-7), and platelets at 14 ×109/L (150-400). The reticulocyte count is 1 ×109/L (25-85). The bone marrow flow cytometry was inconclusive, and the bone marrow trephine showed hypocellularity with a few islands of erythropoiesis. What is the most probable diagnosis?

MRCP2-2249

An 84-year-old man is admitted to the Stroke Unit with symptoms of a left-sided anterior territory ischaemic stroke. His wife reports that he has been experiencing increasing headaches and itchy skin, especially after bathing, for the past few months. He has a history of hypertension, which is managed with two medications, and mild asthma treated with a salbutamol inhaler.During the examination, his blood pressure is found to be 188/100 mmHg, and his pulse is 90 bpm and regular. He exhibits weakness on the left side of his face and left arm, as well as significant dysphasia. Additionally, his haemoglobin levels are elevated at 192g/l.Based on WHO criteria, which of the following factors would be most indicative of a diagnosis of primary polycythaemia?

MRCP2-2250

A 50-year-old man presents to his GP with worsening back pain that has been present for a few months and is no longer relieved with analgesia. He reports feeling constantly tired and has a reduced appetite with associated weight loss, which he had attributed to the analgesics he was taking. The patient had been treated successfully for stage IA Hodgkin’s lymphoma five years ago. On clinical examination, there are positive findings of axillary and inguinal lymphadenopathy, 6 cm splenomegaly, and tenderness along the length of his lumbar spine. Investigations reveal abnormal results for haemoglobin, white cell count, neutrophils, and platelets. What further investigation would you perform to confirm the diagnosis?

MRCP2-2251

A 59-year-old man presents to the hospital after being referred by his GP. He reports experiencing progressive weakness and breathlessness on exertion for the past two weeks, as well as symptoms of indigestion. Upon examination, he appears pale and tachycardic, with a blood pressure of 110/70 mmHg. His heart sounds are normal and his chest is clear. The patient brings in blood test results from his GP, which show a low haemoglobin level, low mean corpuscular volume, and abnormal red blood cell morphology. Which test would be most useful to measure in this patient?

MRCP2-2252

A 68-year-old man presents with increasing fatigue and low back pain for the past five months.Clinical examination reveals a pale-looking man who is slim, with a body mass index (BMI) of 20.5. Blood tests reveal a mild normocytic, normochromic anaemia, low white cell and platelet counts and a high ESR. Blood urea, electrolytes and serum alkaline phosphatase levels are normal, and liver function testing reveals raised total protein and globulin fraction. An X-ray of the lumbosacral spine shows lytic lesions.Which of the following investigations would be most helpful in confirming the diagnosis?

MRCP2-2253

A 35-year-old man presents with sudden fatigue and difficulty breathing. He reports injuring his foot on a rusty nail and noticing a red, spreading area around the wound. Two days later, he began experiencing chills and was brought to the hospital by his family.

During the examination, the patient appears pale and sweaty with a capillary refill time of 4 seconds. His chest is clear, but he is breathing rapidly and shallowly. His heart rate is 123 beats per minute and regular, while his blood pressure is 85/65 mmHg. The wound on his foot is now raised and discolored, with pus collecting under the skin. His cannula site is also bleeding. He is given three liters of intravenous fluid and started on vancomycin and gentamicin.

Hemoglobin: 130 g/L
Platelets: 110 * 10^9/L
White blood cells: 34.0 * 10^9/L
C-reactive protein: 459 ng/mL
Prothrombin time: 18 seconds
Activated partial thromboplastin time: 45 seconds
Fibrinogen: 0.1 g/L
Chest X-ray: patchy bilateral infiltrates
Wound swab: Streptococcus pyogenes

What is the cause of the patient’s abnormal coagulation?

MRCP2-2254

A 54-year-old man presents to the Emergency Department with sudden onset of fatigue and difficulty breathing. He was recently diagnosed with non-Hodgkin’s lymphoma and completed chemotherapy. On examination, he has bilateral crackles in his chest and his blood pressure is 100/70 mmHg with a pulse of 100 bpm. The following laboratory results were obtained: Hb 59 g/l, reticulocytes 0.5%, WCC 6.7 × 109/l, PLT 202 × 109/l, Na+ 137 mmol/l, K+ 4.9 mmol/l, and creatinine 110 µmol/l. What is the most likely cause of his anaemia?

MRCP2-2255

A 68-year-old man presents with severe intractable back pain, headaches, and lethargy. He recently had left lower lobe pneumonia and his symptoms have significantly worsened over the past few days. He is unable to keep any food or fluids down and is vomiting several times during the day. On examination, his BP is 160/95 mmHg and he looks pale. His pulse is 88/min and regular and there are bilateral crackles on auscultation of the chest. Investigations reveal a low haemoglobin level, high potassium and creatinine levels, and positive P-ANCA. What is the most likely diagnosis?