Archives: MRCP Part 2

MRCP2-2118

A 60-year-old man has been diagnosed with extensive oesophageal candidiasis. He has a known history of being HIV positive.

What is the recommended treatment for this condition? Should any additional measures be taken?

MRCP2-2119

A 65-year-old man with a long history of diabetes and previous cerebrovascular accident presents with early satiety, postprandial vomiting, and abdominal distension. He is not experiencing haematemesis or abdominal pain and has regular bowel movements. He is overweight, in atrial fibrillation, and has residual right-sided paralysis. On examination, his abdomen is distended and tympanic, but otherwise soft and non-tender with active bowel sounds. Rectal examination reveals soft brown stool. Investigations show abnormal results for haemoglobin, white cell count, platelets, sodium, potassium, creatinine, mean corpuscular volume, international normalized ratio, urea, albumin, corrected calcium, and glucose. Chest X-ray is normal, and abdominal X-ray shows a dilated stomach. Upper GI endoscopy is normal. What is the most appropriate initial therapy? He is currently on insulin therapy, digoxin, and aspirin.

MRCP2-2120

A 35-year-old Turkish software engineer presents to the Emergency Department with a 24 hour history of excruciating abdominal pain, high fever and muscle pain.
During examination, he is found to be febrile with a temperature of 39.5 °C and has diffuse abdominal tenderness with guarding. Bowel sounds are absent. He has a healed surgical scar from a previous hospitalization with similar symptoms. The surgery was inconclusive.
After conducting a plain abdominal X-ray, which showed no abnormalities, the surgical team was consulted and the patient was started on broad-spectrum intravenous antibiotics. His symptoms resolved after 20 hours of admission. He mentioned that his sister had also been hospitalized with similar symptoms in the past.
What medication would you prescribe to improve the long-term outcomes of this condition?

MRCP2-2121

A 68-year-old man presents with severe and persistent dyspepsia, prompting an urgent upper gastrointestinal endoscopy. During the investigation, a thickened area of gastric folds is discovered in the fundus. Biopsies reveal reactive lymphoid follicles with a dense lymphoid infiltrate extending into the submucosa and epithelium, and a positive Campylobacter-like organism test. What is the best course of action for management?

MRCP2-2122

A 42-year-old accountant presents with abnormal liver function tests during a routine check-up. She reports feeling tired and occasionally experiencing dry eyes, which she attributes to her busy work schedule. She is currently taking birth control pills but no other medication and does not smoke or drink alcohol.
Physical examination is unremarkable.
The following investigations were conducted:
Bilirubin 10 µmol/l 2–17 µmol/l
Alanine aminotransferase (ALT) 20 IU/l 5–30 IU/l
Alkaline phosphatase (ALP) 250 IU/l 30–130 IU/l
AMA Negative
Anti-dsDNA Negative
High-density lipoprotein (HDL) cholesterol 3.5 mmol/l > 1.0 mmol/l
Liver–kidney microsomal antibody (anti-LKM) –
Low-density lipoprotein (LDL) cholesterol 3.0 mmol/l < 3.5 mmol/l
Prothrombin Test (PT) 11 s 10.6–14.9 s
Smooth muscle antibody (SMA) Negative

What treatment plan would you recommend for this patient?

MRCP2-2101

A 65-year-old man presents with severe upper abdominal pain, nausea, and dizziness that has been ongoing for the past day. Upon further questioning, he reveals that he has been experiencing intermittent mild upper abdominal pain for the past month, usually after meals. He has a medical history of hypertension, type 2 diabetes, osteoarthritis, and a heart attack five years ago, for which he received a stent. He is currently taking aspirin, ramipril, amlodipine, metformin, naproxen, and paracetamol.

During his time in the department, he develops diarrhea, and a stool examination reveals melaena. His blood pressure is 110/55 mmHg, and his heart rate is 95 beats per minute. Upon examination, he is tender in the epigastrium with no peritonism and normal bowel sounds. Examination of other systems is normal.

Blood tests show that his Hb is 95 g/l, platelets are 200 * 109/l, WBC is 8 * 109/l, Neuts are 3 * 109/l, Na+ is 145 mmol/l, K+ is 4.5 mmol/l, urea is 12 mmol/l, and creatinine is 102 µmol/l. He is given intravenous fluids and analgesia, and all his regular analgesia except for paracetamol is withheld. Later that day, he is taken to endoscopy, where a 1 cm ulcer is seen in the gastric antrum with an adherent clot. This is clipped and injected with adrenalin. He recovers well from sedation, and upon returning to the ward, his blood pressure is 135/70 mmHg, and his heart rate is 80 beats per minute. He has no further diarrhea or vomiting, and a repeat haemoglobin test shows a level of 121 g/l.

Upon discharge, what advice should he be given regarding his use of non-steroidal anti-inflammatory drugs?

MRCP2-2102

A 55-year-old woman presents to the Emergency Department with vomiting and abdominal pain. She has been experiencing colicky abdominal pain for the past 48 hours, with the worst pain in the center of her abdomen. She has been unable to keep fluids down for the past six hours and has not had a bowel movement in three days. Her abdomen has become distended and she has not passed flatus today.

The patient has a history of ovarian cancer with metastases to her bones, liver, and peritoneum. She has undergone a hysterectomy and bilateral salpingoophorectomy and has received two rounds of chemotherapy. She has no other medical history.

Upon examination, the patient has a tender and tympanic abdomen with no rebound or guarding. There are palpable peritoneal nodules, a 2 cm liver edge, and mild shifting dullness. Bowel sounds are hyperactive. The patient has reduced air entry at both lung bases and mild ankle edema.

An abdominal x-ray reveals dilated loops of small bowel and evidence of ascites. A CT scan of the abdomen with contrast shows small bowel obstruction with an ileal transition point adjacent to a site of peritoneal metastasis. The liver lesions appear stable, and there is no evidence of ureteric obstruction.

The initial measures taken include inserting an NG tube and starting the patient on intravenous fluids and analgesia. What is the best initial measure to help resolve the obstruction?

MRCP2-2103

A 55-year-old woman presents to her GP with complaints of fatigue and body aches, particularly in the pelvic region. She also reports mild shoulder pain but denies any visual changes or jaw pain. Her bowel movements are unchanged, with loose but brown stools. She denies any itching or jaundice. She recently experienced the loss of her sister and has been having difficulty sleeping at night.

The patient has a history of primary biliary cirrhosis and is currently taking ursodeoxycholic acid. On examination, she appears alert with no signs of icterus. Her abdomen is soft, and her liver is palpable 1 cm below the costal margin. She has no asterixis or spider naevi, and her ankles are not swollen. She has full range of motion in all joints with no swelling, but experiences tenderness over the gluteal and quadriceps muscles in her legs.

Lab results show a hemoglobin level of 140 g/l, platelets at 295 * 109/l, and a white blood cell count of 10 * 109/l with 9.4 * 109/l neutrophils. Her bilirubin level is 25 µmol/l, ALT is 40 u/l, ALP is 110 u/l, and γGT is 65 u/l. Her albumin level is 32 g/l, ferritin is 15 ng/ml (range 10-300), B12 is 200 pg/ml (range 180-2000), and folate is 3.4 ng/ml (range >4.0). Her ESR is 17 (range 5-15), and a hip X-ray has been ordered.

What is the most likely diagnosis?

MRCP2-2104

A 50-year-old woman presents to the gastroenterology clinic with a 3-year history of iron deficient anaemia despite iron therapy. She reports feeling constantly tired and lacking energy. She denies any weight loss, haematemesis, melena, or fresh red blood PR. She is a non-smoker, drinks alcohol socially, and has not been on any HRT. On examination, she has pale conjunctiva but is otherwise unremarkable. She has been admitted twice in the past 6 months for blood transfusions and has subsequently dropped her Hb after being discharged.

The patient has undergone extensive testing by her GP, and the results have been included with the referral letter:

Hb 81 g/l
MCV 69 fl
Platelets 299 * 109/l
WBC 6.2 * 109/l

Na+ 141 mmol/l
K+ 4.1 mmol/l
Urea 7.1 mmol/l
Creatinine 101 µmol/l
CRP 11 mg/l

Bilirubin 10 µmol/l
ALP 56 u/l
ALT 21 u/l
Albumin 38 g/l

Serum electrophoresis no paraprotein
Immunoglobulins within normal limits
Ferritin 4 ng/mL (10-150)

USS abdomen: NAD
Transvaginal USS: NAD
CT chest, abdomen and pelvis: NAD
OGD: NAD
Colonoscopy: NAD

Faecal occult blood: positive

The gastroenterologist suspects an occult GI bleed. What is the most appropriate next step in investigating this patient, given her age?

MRCP2-2105

A 57-year-old female presents to the gastroenterology clinic with persistent deranged liver function testing. She has a past medical history of poorly controlled diabetes mellitus type 2, diabetic nephropathy, and retinopathy. On examination, a palpable mass is noted in the right upper quadrant. Investigations reveal an elevated bilirubin and ALT, as well as a positive ANA. The ultrasound shows a bright hyper-echogenic image. What is the most probable diagnosis?