Archives: MRCP Part 2

MRCP2-2161

A 28-week pregnant woman presents with nocturnal itching on her palms and soles of the feet, but no rash. She has not traveled recently and is not jaundiced. Her liver enzymes and serum bile acids are elevated, as shown in the table below. Her prothrombin time is normal, and she has negative anti-nuclear antibodies (ANA) and anti-mitochondrial antibodies. Her urine dipstick reveals 1+ protein, and her blood pressure is 132/80.

ALT: 65 mmol/l
ALP: 171 mmol/l
Bilirubin: 40 mmol/l
Bile acids: 80 mmol/l
Pro-thrombin time: Normal
Anti-nuclear Antibodies (ANA): Negative
Anti-Mitochondrial antibodies: Negative
Urine Protein-Creatinine Ratio: 14 mg/mmol/l

What is the most likely diagnosis?

MRCP2-2162

A 32-year-old man presents to gastroenterology clinic complaining of watery diarrhoea for the past 8 months. He reports having up to 15 bowel movements per day, without any rectal bleeding, and has found no relief with loperamide. The patient has a history of Crohn’s disease, which was diagnosed 5 years ago, and underwent an ileal resection 12 months ago due to an inflammatory stricture. He is a non-smoker and consumes approximately 35 units of alcohol per week. His current medications include omeprazole 20 mg once daily, paracetamol 1g four times daily, and ibuprofen 400 mg three times daily as needed.

The patient’s blood tests reveal a hemoglobin level of 115 g/l, platelets of 395 * 109/l, and a white blood cell count of 10.5 * 109/l. His CRP level is 4 mg/L, and his albumin level is 37 g/l. Other results include normal electrolyte levels, mildly elevated bilirubin and liver enzyme levels, and a slightly elevated creatinine level. His amylase level is within normal limits.

Which diagnostic test is most likely to confirm the patient’s diagnosis?

MRCP2-2163

A 67-year-old woman presents to the gastroenterology clinic with ongoing iron deficiency anaemia. Despite two colonoscopies and an upper GI endoscopy, no significant lesion has been found and her haemoglobin levels continue to decrease despite iron replacement therapy. During examination, her blood pressure is 140/100 mmHg, her pulse is regular at 80 beats per minute, and she appears pale. An ejection systolic murmur is also noted. What is the most suitable approach to investigate her condition?

MRCP2-2164

A 45-year-old woman has recently been diagnosed with diabetes after undergoing surgery for chronic pancreatitis. She has started insulin therapy and visits the clinic to discuss her target HbA1c. Her primary care physician has been aiming for a target HbA1c of 42, but the patient has reported experiencing significant hypoglycemia. Upon clinical examination, there are no notable findings. Her blood pressure is 140/80 mmHg, pulse is regular at 75 beats per minute, and her lungs are clear. She has a midline scar on her abdomen and a body mass index of 22 kg/m.

What would be an appropriate target HbA1c for this patient?

MRCP2-2165

A 30-year-old with newly diagnosed ulcerative colitis is prescribed mesalazine following a recent reduction in high dose steroids. After two weeks, he experiences intense discomfort in his epigastrium and right upper quadrant. What is the probable diagnosis?

MRCP2-2166

A 42-year-old woman presents with unexplained weight loss and occasional diarrhea. She has no significant medical history and is unsure of her family history as she was adopted. During examination, multiple oral papillomas are noted, and there is diffuse swelling in the neck. Colonoscopy reveals scattered small polyps throughout the colon, some of which are removed for histological analysis. Laboratory results show elevated bilirubin and normal liver function tests, as well as low hemoglobin and high platelet count. The histology of the colonic polyp shows a hamartomatous polyp with dilated mucous-filled glands and plasma and lymphocytic infiltration of the lamina propria. What is the most likely diagnosis in this case?

MRCP2-2167

A 73-year-old male under palliative care for metastatic antral gastric carcinoma presented to the Emergency Department on a Saturday night. He was concerned as the gastrostomy tube accidentally came out while he was bathing. This tube was used for feeding purposes. Upon examination, the patient was fully alert, with a blood pressure of 123/75 mmHg and a pulse rate of 94/min. His abdomen was soft and non-tender. Blood tests revealed:

Hb 114 g/l
Platelets 220 * 109/l
WBC 7.7 * 109/l

As the core trainee doctor in charge of the patient’s care, what is the most appropriate course of action to take?

MRCP2-2168

A 32-year-old woman with a history of ulcerative colitis comes to the Emergency Department with an exacerbation. She is opening her bowels some ten times per day with bloody diarrhoea. She tells you that she stopped taking oral mesalazine some eight weeks ago after she found out she is pregnant with her first child. She is now 15 weeks pregnant presents to the Emergency Department with a flare-up. On examination, her blood pressure is 120/80 mmHg and pulse 72 bpm and regular. Her abdomen is tender to palpation but soft, and she has active bowel sounds.

Investigations:
Haemoglobin (Hb) – 110 g/l (normal range: 130-170 g/l)
White cell count (WCC) – 10.5 × 109/l (normal range: 4-11 × 109/l)
Platelets (PLT) – 300 × 109/l (normal range: 150-400 × 109/l)
Erythrocyte sedimentation rate (ESR) – 50 mm/1st hour (normal range: 0-10mm in the 1st hour)
Sodium (Na+) – 140 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+) – 4.0 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine – 80 µmol/l (normal range: 50-120 µmol/l)
Albumin – 35 g/l (normal range: 35-55 g/l)

What is the most appropriate management plan for this patient?

MRCP2-2169

A 50-year-old man presents with chronic diarrhoea. He reports a 12 month history of poorly formed stools, occurring 2-3 times a day which are difficult to flush. He occasionally experiences generalised abdominal discomfort. He denies any blood in his stools.

He also reports an unintentional weight loss of 8kg within this 12 month period. He is perplexed by this, as he still has a good appetite and has not altered his diet.

Despite working full time as a carpenter, he has experienced difficulty kneeling due to hip and knee pain and fatigue.

He has a past medical history of childhood asthma but has otherwise been healthy. His two children are in good health. His father and younger brother have ankylosing spondylitis. He is not taking any regular medication.

On examination, he appears pale and underweight. Cardiopulmonary examination is unremarkable. He has generalised lymphadenopathy with small palpable lymph nodes in his cervical, axillary and inguinal region. There is no organomegaly on abdominal palpation but there is generalised tenderness. His vital signs are within normal limits, except for his temperature which has been consistently between 37.6ºC and 37.8ºC.

Which diagnostic test would be most effective in determining the cause of his symptoms?

MRCP2-2170

A 56-year-old man has been experiencing intermittent lower back and right knee pain and diarrhoea for the past year. He previously underwent investigations for diarrhoea, which revealed non-specific inflammation in the ascending colon. He has lost 3 kg in weight over the past 18 months, drinks occasional alcohol, and smokes 10 cigarettes per day. Cardiovascular and abdominal examination is normal, but tenderness is present over the sacroiliac joints and a small right knee effusion is noted. Blood tests show a low haemoglobin level, high mean corpuscular volume, elevated erythrocyte sedimentation rate, and normal electrolyte and liver function tests. What is the most likely diagnosis?