Archives: MRCP Part 2

MRCP2-2171

A 44-year-old man presents to neurology outpatients with a 2-month history of disinhibited behaviour. His family reports that he has been urinating in public and has been brought home by the police twice recently. He has also been experiencing weight loss over the past year, going from 110 kg to 92 kg. He complains of pain in his lower back, right knee, and left ankle, and has been having diarrhea that is difficult to flush and smells bad.

On examination, he appears pale and has angular cheilitis. His abdomen is distended with some shifting dullness, but no palpable organomegaly is present. He has a positive palmo-mental reflex, and his right knee and left ankle are swollen with minimal tenderness and good range of motion.

Lab results show a low albumin level, low hemoglobin, and an elevated platelet count. A CT scan of the brain is normal, but a duodenal biopsy reveals expanded villi containing macrophages staining positive with periodic acid–Schiff stain.

What is the most likely diagnosis?

MRCP2-2172

A 52-year-old man presents to the outpatient clinic with complaints of weight loss and abdominal pain for the past eight months. He describes the pain as generalised and associated with bloating. He has also noticed an increase in bowel frequency and loose stools. He has lost approximately 10 kg in weight despite having a good appetite. The patient has a history of intermittent knee pain and occasional night sweats. He is a non-smoker and consumes 30-40 units of alcohol per week. On examination, he is thin with diffuse abdominal tenderness and palpable lymph nodes in his neck, axillae, and groins. Investigations reveal low haemoglobin, low albumin, and negative stool culture. What is the most appropriate treatment for this patient?

MRCP2-2173

A 55-year-old woman has been diagnosed with Wilson’s disease. As you review her blood test results, which of the following would you anticipate finding in a patient with this condition?

MRCP2-2174

A 19-year-old woman who works as a teaching assistant in a nursery has been experiencing shaking in her right arm when writing on the blackboard and has been dropping cups of tea due to shaking. She has also noticed poor balance and falls easily when playing with the children. These symptoms have developed gradually over the course of 15 months. During her neurological examination, a postural tremor of the upper limbs was observed, with the right side being worse than the left. Additionally, she has a broad-based ataxic gait and some rigidity in her right upper limb. The slit lamp examination revealed brown-green deposits in Descemet’s membrane of the cornea. The rest of the clinical examination was unremarkable. What is the most appropriate treatment for the underlying condition?

MRCP2-2150

A 78-year-old woman experienced a GI bleed 8 months ago due to NSAID use for osteoarthritis. During an endoscopy, a duodenal ulcer was discovered and treated. She has now returned with acute haematemesis after being prescribed diclofenac with misoprostol again. Upon admission, her haemoglobin level is 56 g/L. An OGD was performed, revealing a single bleeding vessel on the duodenum’s posterior wall. Despite adrenaline injection and clipping, the bleeding could not be controlled. What is the next step in managing her condition?

MRCP2-2151

A 29-year-old male presents with frank haematemesis. The patient admits to drinking 1L of vodka daily. He has a background of alcoholic liver disease. On examination, there is evidence of gross abdominal ascites, flapping tremor and jaundice. His blood pressure is 96/50 mmHg, pulse rate 105 bpm. You suspect variceal bleeding as the cause of his symptoms.

Bilirubin 83 µmol/l
ALP 52 u/l
ALT 253 u/l
γGT 151 u/l
Albumin 28 g/l

Hb 98 g/l
Platelets 51 * 109/l
WBC 2.5 * 109/l

What other initial management, in addition to urgent endoscopic assessment and starting terlipressin, can be done to reduce mortality?

MRCP2-2152

A 57-year-old man comes to the clinic feeling extremely down about the weight he has gained in the last few years. This is amidst the stress of caring for his elderly parents. He has no notable medical history and is not taking any medication. During the examination, his blood pressure is 150/90 mmHg and his BMI is 33. A fasting glucose level is measured at 6.8 mmol/l. What is the most suitable course of action to take next?

MRCP2-2153

A 48-year-old man is brought to the hospital after being found on the street with hypothermia. Upon admission, his blood ethanol level is measured at 2.4 g/l. Despite being warmed up, he continues to display confusion, indifference, and inattentiveness 24 hours later. He has no significant medical history. His vital signs are stable, with a pulse of 72 beats per minute, blood pressure of 105/60 mmHg, and temperature of 37.2ºC. His random blood sugar is 3.9 mmol/l.

During examination, the man appears disheveled and has multiple spider naevi, ascites, and a mild liver flap. His eye movements are abnormal, with horizontal nystagmus on lateral gaze in both directions, and he has a slow, wide-based gait. He has experienced urinary incontinence several times during his admission but has not had a bowel movement in two days.

What is the most appropriate course of treatment for this patient?

MRCP2-2154

A 43-year-old widow presents with a one week history of progressive confusion and unsteady gait. She works as a waitress and lives in poor social circumstances.

On examination, she is malnourished and disorientated. She has nystagmus and is unable to abduct either eye. The pupils are sluggish and unequal. Ankle jerks are absent but upper limb reflexes are present.

Shortly after her admission, you are called to the ward as she has become very drowsy and has collapsed on the floor.

Investigations on admission showed:

Haemoglobin 114 g/L (115-165)

MCV 99 fL (80-96)

White blood cells 5.6 ×109/L (4-11)

Platelets 230 ×109/L (150-400)

Serum sodium 129 mmol/L (137-144)

Serum potassium 3.2 mmol/L (3.5-4.9)

Serum bilirubin 27 µmol/L (1-22)

Serum gamma glutamyl transferase 440 U/L (4-35)

Serum alkaline phosphatase 180 U/L (45-105)

Serum aspartate aminotransferase 90 U/L (1-31)

Serum alanine aminotransferase 45 U/L (5-35)

Serum albumin 33 g/L (37-49)

Prothrombin time 12 secs (11.5-15.5)

What is the first investigation that should be done?

MRCP2-2155

A 38-year-old woman is brought to the hospital after being found on the street with hypothermia. Upon admission, her blood ethanol level is measured at 2.4 g/l. Despite her body temperature being corrected, she continues to display intermittent confusion, indifference, and inattentiveness 24 hours later. She has no significant medical history. Her vital signs are stable with a pulse of 72 beats per minute, blood pressure of 105/60 mmHg, and temperature of 37.0ºC. On examination, she appears disheveled and underweight with poor dental hygiene. Her eye movements are abnormal with horizontal nystagmus on lateral gaze in both directions, and she has a slow, wide-based gait. She has also experienced urinary incontinence during her admission. What is the most likely diagnosis?