Archives: MRCP Part 2

MRCP2-4541

A 65-year-old woman presents to the Emergency department with a one-week history of increasing breathlessness and coughing up small amounts of blood. She also reports frequent nosebleeds and headaches over the past two months, as well as feeling generally lethargic and losing weight. On examination, there are no signs of cyanosis, finger clubbing, pallor, or skin rash. The pulse is 100 beats/min and BP is 135/95 mmHg. Respiratory rate is 28 breaths/min, chest expansion is moderate, and inspiratory crackles are heard at the left lung base.

The following investigations were conducted: Hb 100 g/L (115-165), WCC 19.9 ×109/L (4-11), Platelets 540 ×109/L (150-400), Plasma sodium 139 mmol/L (137-144), Plasma potassium 5.3 mmol/L (3.5-4.9), Plasma urea 30.6 mmol/L (2.5-7.5), Plasma creatinine 760 µmol/L (60-110), Plasma glucose 5.8 mmol/L (3.0-6.0), Plasma bicarbonate 8 mmol/L (20-28), Plasma calcium 2.23 mmol/L (2.2-2.6), Plasma phosphate 1.7 mmol/L (0.8-1.4), Plasma albumin 33 g/L (37-49), Bilirubin 8 µmol/L (1-22), Plasma alkaline phosphatase 380 U/L (45-105), Plasma aspartate transaminase 65 U/L (5-35). Arterial blood gases on air reveal: pH 7.2 (7.36-7.44), pCO2 4.0 kPa (4.7-6.0), pO2 9.5 kPa (11.3-12.6). ECG shows sinus tachycardia and chest x-ray reveals a shadow in the left lower lobe. Urinalysis shows blood +++ and protein ++.

Which of the following would you expect to be positive in this patient?

MRCP2-4537

A 55-year-old man of Afro-Caribbean descent presents to the clinic with complaints of fever, joint pain, and lethargy. He has also noticed a rash on his arms and neck that comes and goes over the past six months. He has a medical history of congestive heart failure and chronic kidney disease due to hypertension. His current medications include bisoprolol, aspirin, and hydralazine/isosorbide dinitrate. On examination, there is no joint swelling, but he has patches of scaling on his neck and forearms. Laboratory tests reveal positive rheumatoid factor, anti-nuclear antibody, anti-single stranded DNA, and anti-histone antibodies, but negative anti-extractable nuclear antigen. What is the most likely diagnosis?

MRCP2-4545

A 63-year-old man presents with a week of right-sided shoulder pain. He denies any trauma and denies radiation of the pain. There is no associated weakness or numbness. The pain is more noticeable at the extremities of movement and is affecting activities of daily living. His past medical history includes type 2 diabetes mellitus and asthma.

Upon examination, the affected shoulder is painful and restricted, with both active and passive movement. External rotation is most severely limited. Pain is elicited when applying direct pressure to the coracoid process.

What is the most appropriate next step given the most likely diagnosis?

MRCP2-4534

A 55-year-old woman presents with an infective exacerbation of bronchiectasis. Pseudomonas aeruginosa has been identified in multiple sputum cultures from the community and her GP initiated oral ciprofloxacin. However, after four days of treatment, she has developed worsening fever, hypoxia, and breathlessness, and now requires oxygen. Bilateral infiltrates are visible on her chest x-ray, and coarse crepitations are heard throughout her lungs.

What is the best course of action in this case?

MRCP2-4531

A 32-year-old with asthma is currently using a salbutamol inhaler on an as-needed basis and budesonide 200 μg inhaler twice per day, but their symptoms are not well controlled. What would be the recommended treatment escalation based on the latest NICE guidelines?

MRCP2-4538

A 75-year-old male presents to the Emergency Department with a two-day history of right temporal, throbbing headache, constant in nature and 8/10 severity. He reports this being the first ever episode of this headache and is different to his previous migraines, which have been typically in the left occipital region, lasting minutes, and fairly stereotyped over the past 50 years. Apart from migraines, he has no other medical history.

On examination, his right scalp is tender and a prominent right temporal artery is noted. He is apyrexic with no skin rashes. His blood tests are as follows:

Hb 140 g/l
Platelets 550 * 109/l
WBC 11.0 * 109/l
ESR 80 mm/hr

Na+ 145 mmol/l
K+ 4.5 mmol/l
Urea 9.8 mmol/l
Creatinine 110 µmol/l
CRP 25 mg/l

You empirically start him on 60mg prednisolone. He undergoes temporal artery biopsy within 24 hours of his admission demonstrating no signs of temporal arteritis.

What is the most appropriate next step?

MRCP2-4539

A 70-year-old male was recently prescribed alendronate for osteoporosis treatment after experiencing a fragility fracture. However, he presents to your clinic with concerning upper gastrointestinal adverse effects. What would be the most suitable course of action for his management?

MRCP2-4535

A 85-year-old female presents to the emergency department with a four-day history of increasing shortness of breath and worsening of a chronic productive cough. She does not speak English, but her medical records indicate that she recently moved from rural India to live with her family two years ago. There is no known underlying lung condition. Upon examination, bilateral expiratory wheeze and hyperexpanded lungs are observed, with no clear inspiratory crackles. Heart sounds appear normal, and mild bilateral pitting edema is present. Her saturation measures 88% on air via pulse oximeter, and her respiratory rate is 24 to 28 per minute. A chest radiograph shows hyperexpanded lungs with mild bibasal fibrotic changes but no focal signs of consolidation. She has no history of smoking or alcohol use. Her blood tests reveal:

– Hb 15.0 g/dl
– Platelets 211 * 109/l
– WBC 11.4 * 109/l
– Neutrophils 9.5 * 109/l
– Urea 8.4 mmol/l
– Creatinine 112 µmol/l
– CRP 37 mg/l

What is the most likely diagnosis?

MRCP2-4532

An 83-year-old man is brought to the Emergency Department by ambulance following a visit from his General Practitioner. The GP noted that he was experiencing severe shortness of breath and coughing up rust-coloured sputum. He is a smoker, consuming ten cigarettes per day. Upon examination, he displays crackles and bronchial breathing on the right side, indicative of pneumonia. At the hospital, his respiratory rate is 24 breaths per minute, and he requires 3 litres of oxygen via nasal cannulae to achieve oxygen saturations of 96%. A chest X-ray confirms right basal consolidation, and he is started on antibiotics for community-acquired pneumonia (CAP). He responds well to treatment and is ready for discharge after five days. What feature of CAP necessitates a repeat chest X-ray at six weeks?

MRCP2-4536

A 31-year-old man presents with a history of recurrent ulcers over several months. He reports experiencing oral ulcers regularly, with multiple occurring at a time, which typically resolve within a week. Additionally, he has been experiencing painless genital ulcers. He has recently attended the eye casualty department twice, where he was diagnosed with uveitis. On examination today, he has several oral ulcers and genital ulcers. What findings would support the probable diagnosis?