Archives: MRCP Part 2

MRCP2-2223

A 50-year-old man presented to the outpatient clinic with anaemia. He had been experiencing fatigue and low back pain for the past three months, without any history of trauma. A plain x-ray of his lumbar spine revealed a lytic lesion in the body of the fifth lumbar vertebra (L5). Further investigations showed a haemoglobin level of 105 g/L (130-180), WBC count of 4.0 ×109/L (4-11), platelet count of 175 ×109/L (150-400), and serum corrected calcium level of 2.4 mmol/L (2.2-2.6). Bence Jones proteins were detected in his urine, and a skeletal survey showed increased uptake in the L5.

Which of the following treatments would be effective in reducing the risk of pathological fracture?

MRCP2-2224

A 32-year-old man with normal cardiac and respiratory function is undergoing the ABVD chemotherapy regimen for his stage IIB Hodgkin’s lymphoma. He has successfully completed the first three cycles of chemotherapy without any complications. However, after finishing the fourth cycle, he complains of exertional dyspnoea and a dry cough. He has no fever, and his chest x-ray and ECG are normal. What is the most probable diagnosis?

MRCP2-2201

A 68-year-old man arrives at the emergency department after falling and injuring his back. He had been experiencing lower back pain prior to the fall, which only worsened slightly after the incident. A CT scan reveals lytic lesions in his lumbar vertebrae, leading to suspicion of multiple myeloma. Blood and urine tests further support this diagnosis, and he is scheduled for a bone marrow biopsy. What test can provide prognostic information before the biopsy for this patient?

MRCP2-2202

A 31-year-old male presents with a progressive worsening non-specific lethargy. 8 months ago, he had returned from an active holiday from Australia and now feels lethargic to the point that he can no longer work in his job as a graphic designer. In this period, he has been treated for two deep vein thromboses with low molecular heparin, the first initially attributed to his return flight from Australia. He reports two episodes of rose coloured urine over the past 3 months and intermittent episodes of abdominal cramps that his GP had diagnosed to be irritable bowel syndrome.

On examination, you note mild conjunctival pallor and jaundiced sclera. Respiratory, cardiovascular and abdominal examinations are unremarkable. His blood results are as follows:

Hb 78 g/l
MCV 92 fl
Platelets 276 * 109/l
WBC 4.1 * 109/l
Reticulocytes 18%
Haptoglobin 2 (normal range 41-165 mg/dL)
LDH 2128 (normal range 140-280 units/L)
Coombs’ test negative at 4 and 37 degrees

What is the definitive treatment for the underlying condition?

MRCP2-2203

A 65-year-old woman visits her GP complaining of a swollen left leg accompanied by pain that started a day ago. She has a medical history of hypertension and heart failure and is currently taking bisoprolol, ramipril, amlodipine, and furosemide. Her mobility is significantly limited.

During the examination, the left calf appears red and is 4 cm larger than the right. There is tenderness over the deep venous system, and bilateral, symmetrical pedal oedema is present. The left thigh shows no abnormalities.

What would be the most appropriate course of action to take next?

MRCP2-2204

A 75-year-old man comes to the clinic with muscle bleeds and extensive ecchymoses. His platelet count and PT are normal, but his APTT is prolonged at 42 seconds. Plasma mixing studies fail to correct the prolonged APTT, and a factor VIII inhibitor is identified. What is the recommended treatment for acquired haemophilia A in this case?

MRCP2-2205

A 40-year-old man presents to the haematology clinic with a 6-month history of easy bruising and prolonged bleeding. He reports no other symptoms and is generally feeling well. The patient has a history of rheumatoid arthritis that is poorly controlled, with frequent flares. There is no family history of bleeding disorders.

Lab results:

– Hb: 126 g/L (135-180)
– Platelets: 201 * 109/L (150 – 400)
– WBC: 5.5 * 109/L (4.0 – 11.0)
– PT: 12 secs (10-14 secs)
– APTT: 45 secs (25-35 secs)
– Fibrinogen: 2.2 g/L (2 – 4)
– D-Dimer: 300 ng/mL (< 400)
– Von Willebrand Factor: 100 IU/dL (50-150)
– Reduced Factor VIII levels

What is the most likely diagnosis?

MRCP2-2206

A 35-year-old woman, who is 50 days post matched unrelated donor (MUD) allogeneic bone marrow transplant for her acute myeloid leukaemia in second remission, presents with loose bowel movements and a maculopapular rash on her extremities. Her liver function tests reveal an elevated bilirubin and alkaline phosphatase, while ALT and GGT are spared. The diagnosis is acute graft versus host disease. What is the best initial approach to managing this condition?

MRCP2-2207

A 25-year-old female presents with severe abdominal pain. This is her third presentation this year. She was previously told that the abdominal pain was medically unexplained. On examination you note peripheral neuropathy of her lower limbs. Her blood pressure is 160/110 mmHg and heart rate 125 beats per minute.

Blood results are as follows:

Hb 115 g/l Na+ 132 mmol/l
Platelets 468 * 109/l K+ 3.8 mmol/l
WBC 14.2 * 109/l Urea 8.6 mmol/l
Neuts 10.8 * 109/l Creatinine 72 µmol/l
Lymphs 1.6 * 109/l CRP 28 mg/l
Eosin 0.2 * 109/l

Urine Increased levels of delta aminolevulinic acid and porphobilinogen

What treatment is indicated?

MRCP2-2208

A 55-year-old man presents with recurrent episodes of bleeding gums, nosebleeds and intermittent haematuria over the past 6 weeks. He has no significant medical history but is a heavy smoker of 25 pack years. He drinks alcohol occasionally.

During examination, scabs and dried blood are noted on mucous membranes. No arthritis or cutaneous abnormalities are observed. The nasal bridge appears normal. His conjunctiva is pale, and respiratory, abdominal and cardiovascular examination is unremarkable. The following blood tests are obtained:

– Hb 37 g/l
– MCV 87 fl
– Platelets 17 * 109/l
– WBC 44.0 * 109/l
– Blood film myeloblasts with elongated, needle-like cytoplasmic inclusions

– Na+ 147 mmol/l
– K+ 3.2 mmol/l
– Urea 7.8 mmol/l
– Creatinine 70 µmol/l

What is the most probable underlying diagnosis?