Archives: MRCP Part 2

MRCP2-2146

A 60-year-old male presents with a 6-month history of epigastric discomfort and two episodes of black tarry stools in the past 5 weeks. Over the past year, he reports a change in his bowel habit of almost predominantly loose bowel motions with no mucous or blood. He has no past medical history but acknowledges that he does not lead the healthiest lifestyle: he is an active smoker with a 45 pack year history and drinks at least 35 units of alcohol per week. However, he has been actively trying to improve a sedentary lifestyle as a lorry driver by using the gym twice a month, reporting 1.5 stones weight loss over the past 5 months. He had been started on increasing doses of omeprazole by his GP with no improvements in his symptoms. His mother died of pancreas adenocarcinoma aged 55. On examination, his abdomen is soft and non-tender with no organomegaly. Abdominal XR was unremarkable. Stool culture revealed no organisms on microscopy. An oesophageal-gastric endoscopy demonstrated multiple gastric and duodenal ulcers, biopsies of which were H Pylori negative. His blood tests are as follows:

Hb 130 g/l
Platelets 300 * 109/l
WBC 9.6 * 109/l
Na+ 140 mmol/l
K+ 4.6 mmol/l
Urea 8.1 mmol/l
Creatinine 62 µmol/l
Bilirubin 23 µmol/l
ALP 32 u/l
ALT 122 u/l
γGT 84 u/l
Adj calcium 2.23 mmol/l
Phos 1.32 mmol/l
Random blood glucose 7.3 mmol/l

Which of the following tests would provide a definitive diagnosis?

MRCP2-2147

A 45-year-old heavy smoker presents to her general practitioner with increasing heartburn and indigestion. She works as a waitress and is able to walk around the restaurant without difficulty. A recent trial of omeprazole has not improved her symptoms. She also admits to drinking 15 units of alcohol per week. There was an admission with chest pain some 9 months previously and she has lost 2 kg in weight over the past month.

On examination, her BP is 118/70 mmHg, with pulse 80/min and regular. She has mild epigastric tenderness. Full blood count is normal.

What is the most appropriate investigation to perform in this case?

MRCP2-2148

A 19-year-old man presents to the emergency department on a Saturday night after collapsing in a public bar and vomiting bright red vomitus. He has a history of familial adenomatous polyposis and has undergone a prophylactic colectomy with an ileo-anal pouch. On examination, he appears well with normal vital signs and unremarkable findings. Laboratory results show a normal hemoglobin level, white blood cell count, and platelet count. An upper GI endoscopy is also normal. What is the next step in managing this patient?

MRCP2-2149

You assess a 27-year-old female patient at the gastroenterology clinic who had previously undergone treatment for H. pylori with omeprazole, amoxicillin, and clarithromycin. Despite being on PPI therapy, she still experiences epigastric discomfort. You suspect that she may have an ongoing H. pylori infection and order a urea breath test to investigate. What is the duration for which the patient needs to discontinue her PPI therapy before undergoing the urea breath test?

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?