Archives: MRCP Part 2

MRCP2-2156

A 27-year-old woman presents to the gastroenterology clinic with a flare of ulcerative colitis. She reports experiencing bloody diarrhoea for the past week, with up to 6 bowel movements per day. She denies having a fever and reports compliance with her mesalazine enemas, which have not been effective. She has no significant medical history, occasional smoking habits, and drinks alcohol once or twice a week. Her last menstrual period was 3 weeks ago.

On physical examination, she is afebrile, with normal vital signs except for mild hypotension, which is her baseline. Her abdomen is soft, with mild tenderness in the left iliac fossa.

Laboratory tests reveal a hemoglobin level of 118 g/L (normal range for females: 115-160 g/L), platelet count of 250 * 109/L (normal range: 150-400 * 109/L), white blood cell count of 11.7 * 109/L (normal range: 4.0-11.0 * 109/L), and an erythrocyte sedimentation rate of 25 mm/hr (normal range: <10mm/hr). A pregnancy test is negative. An abdominal X-ray is unremarkable. A flexible sigmoidoscopy is scheduled for the next day, which reveals mild inflammation. A previous colonoscopy showed colitis up to the ileocaecal valve. Based on the patient’s clinical history, what interventions should be considered?

MRCP2-2130

A 42 year-old man, working as a pastry chef, presents to his GP with a complaint of pale, foul-smelling stools and a recent weight loss of 6 kg over the past two months. He has a medical history of occasional acid reflux, for which he was recently prescribed omeprazole. He reports drinking several glasses of wine daily and has a smoking history of five packs per year.

Upon conducting blood tests, the following results were obtained:

– Hemoglobin (Hb): 9.9 g/dL
– Mean corpuscular volume (MCV): 115 fl
– Platelets: 280 * 109/l
– White blood cells (WBC): 7.1 * 109/l
– Sodium (Na+): 136 mmol/l
– Potassium (K+): 4.0 mmol/l
– Urea: 3.2 mmol/l
– Creatinine: 52 mol/l
– Bilirubin: 15 mol/l
– Alkaline phosphatase (ALP): 140 u/l
– Alanine transaminase (ALT): 50 u/l
– Gamma-glutamyl transferase (γGT): 210 u/l
– Albumin: 39 g/l
– Vitamin B12: 120 ng/l
– Faecal elastase: 98 g/g (normal > 200)

What is the most appropriate next investigation?

MRCP2-2131

A 45-year-old teacher presents with iron deficiency anaemia. She mainly consumes white meat and fish but insists that her diet is diverse enough. She also complains of frequent diarrhoea and has lost 8 kg in the past year.
During examination, her BMI is 23, but no other abnormalities are detected.
The following investigations are conducted:
Haemoglobin (Hb) 102 g/l 115–155 g/l
Mean corpuscular volume (MCV) 82 fl 76–98 fl
Serum ferritin 12 µg/l 10–120 µg/l
Serum folate 1.8 µg/l 2.0–11.0 µg/l
Albumin 36 g/l 35–55 g/l
Immunoglobulin G (IgG) 14 g/l 5–16 g/l
IgA 4.2 g/l 1.0–4.0 g/l
IgM 2.8 g/l 0.5–2.0 g/l
An OGD is performed, which reveals mild duodenitis. Small bowel biopsies are taken and are reported as showing subtotal villous atrophy.
What is the most probable diagnosis?

MRCP2-2132

A 27-year-old man presents to the outpatient clinic with a 2-month history of weight loss, cramping lower abdominal pain, and increasing stool frequency. He reports passing stools with blood and mucous, and occasionally pure blood with no feces. He has no regular medications and is normally healthy. On examination, he has a low-grade fever of 37.5 and appears pale. His abdomen is tender across the lower half. The GP had previously checked his bloods, which showed:

– Hb 110 g/l
– Platelets 400 * 109/l
– WBC 12.0 * 109/l
– Neuts 9.0 * 109/l
– Na+ 139 mmol/l
– K+ 4.5 mmol/l
– Urea 4.0 mmol/l
– Creatinine 89 µmol/l
– CRP 60 mg/L (<10)
– Bilirubin 8 µmol/l
– ALP 78 u/l
– ALT 34 u/l
– Albumin 36 g/l

Stool cultures were negative. He is admitted for a flexible sigmoidoscopy, which reveals mild colitis extending to the mid-descending colon. Biopsies are taken, showing mild colitis of indeterminate cause. He is started on IV hydrocortisone 100mg QDS and mesalazine, which leads to clinical improvement. He tests positive for anti-Saccharomyces cerevisiae antibodies but negative for pANCA. What is the most likely reason for his colitis?

MRCP2-2133

A worried 28-year-old woman visits her GP practice due to two days of painless rectal bleeding. Her bowel habit remains unchanged, and she has no other accompanying symptoms or travel history. She is particularly anxious as her mother, who is 47 years old, was recently diagnosed with bowel cancer. Further questioning reveals that her maternal grandfather passed away after suffering from bowel cancer. The GP suspects an inherited tendency towards the disease, specifically familial adenomatous polyposis. What is the most common physical feature associated with this condition?

Note: The only change made was to the age of the woman from 29 to 28.

MRCP2-2134

A 30-year-old Iraqi student presented to the Emergency Department multiple times with fever, arthralgia, and abdominal pain. He had a history of appendicectomy and cholecystitis. The pain was associated with constipation that turned into diarrhea when the pain subsided. On examination, he had a pyrexia of 38.5 °C, generalized rebound tenderness in the abdomen, and diminished bowel sounds. He also had bilateral swollen knees, and clear fluid was aspirated from each joint. CT scan was unremarkable. Laboratory investigations showed elevated CRP and ESR, and protein was detected in his urine. What is the most likely diagnosis?

MRCP2-2135

A 55-year-old man visits his primary care physician with complaints of fatigue and joint pains. He has no significant medical history and does not take any regular medications. He is a non-smoker and does not consume alcohol.

During the examination, the physician observes a ‘slate-grey’ appearance of the skin and tenderness at the 2nd and 3rd MCP joints on the left hand, but no apparent swelling. The cardiovascular, respiratory, and abdominal examinations are normal.

The following blood tests are conducted:

– Hb: 140 g/L (Male: 135-180, Female: 115-160)
– Platelets: 195 * 109/L (150-400)
– WBC: 4.8 * 109/L (4.0-11.0)
– Na+: 137 mmol/L (135-145)
– K+: 4.1 mmol/L (3.5-5.0)
– Urea: 5.8 mmol/L (2.0-7.0)
– Creatinine: 92 µmol/L (55-120)
– CRP: 3 mg/L (<5)
– 9am cortisol: 410 nmol/L (170-420)
– TSH: 2.5 mU/L (0.5-5.0)
– HbA1c: 41 mmol/L (<48) X-ray of the hand reveals hook-like osteophytes at the 2nd and 3rd MCP joints on the left hand. Considering the probable diagnosis, what is the most effective screening test for this condition in the general population?

MRCP2-2136

A 50-year-old man with a history of chronic hepatitis B infection and taking tenofovir presents for routine review in the hepatology clinic. He denies smoking or drinking alcohol. On examination, there are no notable findings. His blood tests reveal bilirubin, ALP, ALT, and γGT within normal limits, but his albumin is slightly low. Further testing shows hepatitis B DNA is detectable, while surface antigen and core antibody are positive, and e antigen and surface antibody are negative. In this clinical context, which parameter is the most reliable indicator of the risk of developing cirrhosis?

MRCP2-2137

A 50-year-old Russian immigrant with a history of haemophilia A presents after a car accident. He receives four units of blood and recombinant factor VIII concentrate. He drinks 10 units of alcohol per week and denies any past iv drug use. As a child in Russia, he underwent surgery. His test results show elevated ALT, γGT, ALP, and bilirubin levels. You suspect he may have viral hepatitis. What is the most likely diagnosis?

MRCP2-2138

A 57-year-old man with chronic hepatitis C presents with a Glasgow Coma Scale (GCS) of 5/15 and a temperature of 38.0 °C. His medication includes tramadol, diclofenac, and furosemide. He has coarse crackles at his right lung base, a distended abdomen with shifting dullness, and his pupils are equal and reactive with flexor plantar responses. He is transferred to the Intensive Care Unit and receives fluid resuscitation and broad-spectrum antibiotics for his chest. Investigations reveal abnormal results for haemoglobin, white cell count, platelets, sodium, potassium, creatinine, mean corpuscular volume, international normalised ratio, urea, bilirubin, alanine aminotransferase, alkaline phosphatase, and albumin. Computed tomography scans show cerebral atrophy and a cirrhotic liver with free fluid in the pelvis. Three days later, he becomes oliguric and repeat renal function tests reveal low sodium and potassium levels, high urea and creatinine levels, and low urinary sodium levels. Blood culture is negative and ascitic tap shows no organisms but a polymorphic neutrophil count of 30 cells/mm3. What is the most likely diagnosis for his worsening renal function?