A 56-year-old woman with a history of Sjogren’s syndrome visits her GP complaining of fatigue. Upon physical examination, no abnormalities are found. The patient does not take any regular medication except for artificial tears, drinks 10 units of alcohol per week, and does not smoke. The GP refers her to your clinic after routine blood tests reveal the following results:
A 35-year-old man presented to the outpatient clinic with a six-week history of bloody diarrhoea, opening his bowels up to eight times per day and at least twice at night. He also reported an ache in the left iliac fossa. He had experienced similar episodes over the past decade but had never sought medical advice. His general practitioner had prescribed Loperamide. On examination, he appeared generally well but had yellow sclera and mild tenderness in the left iliac fossa. Sigmoidoscopy revealed an inflamed mucosa. Laboratory results showed liver dysfunction with elevated bilirubin, aspartate transaminase, alkaline phosphatase, and gamma gluteryltransferase. The cause of the liver dysfunction is being asked.
MRCP2-2085
A 42-year-old white male presents to his GP with a long-standing history of joint pains in multiple joints, which has gradually affected his ability to work on his farm. He had previously consulted another doctor but no diagnosis was made. He has been taking ibuprofen with partial relief. Recently, he has also been experiencing fever, weight loss, and diarrhoea. He denies any symptoms related to his genitourinary or eyes. He does not consume tobacco, alcohol or drugs.
During the examination, the patient was found to have generalised lymphadenopathy and non-deforming arthritis. A small intestinal biopsy revealed macrophage infiltration into the lamina propria.
What is the most probable diagnosis?
MRCP2-2086
A 35-year-old man presents with chronic diarrhoea and abdominal pain for almost a year. He has unintentionally lost a significant amount of weight and has a history of arthralgia and fever for the past decade. He recalls mosquito bites from a trip to Gambia when he was 18 and has been experiencing lapses in memory and poor performance at work. On examination, he appears emaciated with mild polyarthralgia and an ataxic gait. His blood tests reveal low hemoglobin, low ferritin, and abnormal electrolyte levels. A small bowel biopsy is ordered. What histological abnormality is likely to be found?
MRCP2-2087
A 49-year-old man presents to the Emergency Department with large-volume haematemesis. The blood is bright red and he reports experiencing 3 separate episodes over the preceding 12 hours. Despite a previous diagnosis of alcoholic liver disease, he continues to drink a bottle of whiskey per day.
On examination, he is pale and clammy. His pulse is 130 bpm and his blood pressure is 85/60 mmHg. His chest is clear and his heart sounds are normal. His abdomen is distended with mild right upper quadrant tenderness and evidence of shifting dullness.
He is resuscitated with intravenous fluids and 4 units of cross-matched blood are requested. Terlipressin and intravenous ceftriaxone are administered whilst an emergency endoscopy is arranged. He subsequently undergoes variceal band ligation and returns to the ward, where he passes an uneventful night.
Over the next few days, he has two further episodes of large-volume haematemesis which are only partly controlled by repeat endoscopic intervention. He is reviewed by the Gastroenterology Consultant and a plan to refer the patient for a transjugular intrahepatic portosystemic shunt (TIPSS) is made.
What is the greatest contraindication to a TIPSS procedure in this patient?
MRCP2-2088
You are requested to assess a 44-year-old female patient who is currently admitted to the ward. She is presenting with confusion and disorientation. During the examination, you observe ascites, hyperreflexia, and jaundice.
The patient’s vital signs are as follows: respiratory rate of 18 breaths per minute, saturations of 98% on room air, blood pressure of 110/55 mmHg, heart rate of 95 beats per minute, and temperature of 36.7ºC.
The patient’s laboratory results are as follows: Hb of 110 g/L (normal range for females: 115-160), platelets of 75 * 109/L (normal range: 150-400), and WBC of 4.0 * 109/L (normal range: 4.0-11.0).
The patient’s bilirubin level is 122 µmol/L (normal range: 3-17), ALP is 135 u/L (normal range: 30-100), ALT is 98 u/L (normal range: 3-40), γGT is 70 u/L (normal range: 8-60), and albumin is 20 g/L (normal range: 35-50).
Upon reviewing the patient’s medical records, you discover that she was admitted to the hospital a week ago due to haematemesis. Gastroscopy revealed oesophageal varices, which were banded. However, the patient experienced another episode of bleeding post-procedure, and banding was not possible. As a result, she required a transjugular intrahepatic portosystemic shunt (TIPPS).
What is the probable cause of the patient’s confusion?
MRCP2-2089
A 27-year-old woman is admitted with a flare-up of her ulcerative colitis. She has been receiving treatment with intravenous steroids and ciclosporin. On day 4 of her admission, you are asked to assess her for discharge. During the examination, her temperature is 37.7 °C, and her pulse rate is 91/min. She has had 9 bowel movements today, which is an improvement from the >10 times a day on admission. She has been eating and drinking and feels ready to go home. Her abdomen is mildly tender in the left flank, but is otherwise soft with active bowel sounds present. The current blood test results are as follows:
What would be your next step in managing this patient?
MRCP2-2090
A 32-year-old patient visits the endocrinology clinic with complaints of low energy, difficulty with erections and sexual desire. The GP referred him after a morning serum testosterone test showed low levels. The patient has a history of T1DM and has been experiencing symptoms of acid reflux for the past six months. His current medications include Levemir, Novorapid, omeprazole and metoclopramide. Although his capillary sugar levels have been normal, his prolactin levels are elevated. What is the most appropriate course of action?
MRCP2-2091
A 65-year-old man presents to the Emergency Department with profuse, foul smelling diarrhoea, abdominal pain and fever.
His medical history includes hypertension, gout and osteoarthritis. He usually has regular bowel habits and has not experienced any recent changes. He underwent an endoscopy for dyspepsia two weeks ago and was diagnosed with gastritis. He is currently taking amlodipine 5mg, omeprazole 20mg, simvastatin 20mg, and uses a salbutamol inhaler one puff as required. He has no known drug allergies. He recently returned from a business trip to Paris.
Upon examination, he appears unwell with a heart rate of 110 beats/min and regular, a blood pressure of 100/60 mmHg, oxygen saturations of 96% on air, and a temperature of 38ºC. He is peripherally shut down with a capillary refill time of 3 seconds. Abdominal examination reveals a distended and diffusely tender abdomen with guarding.
An abdominal X-ray shows a loss of bowel wall architecture and thumb-printing consistent with the diagnosis. An erect chest x-ray shows clear lung fields with no air under the diaphragm.
What is the most likely cause of his symptoms?
MRCP2-2092
A 55-year-old man with a history of alcoholic liver disease is exhibiting confusion on the ward, as noted by the nursing staff. Upon examination, his heart rate is elevated at 100 beats per minute, but his blood pressure remains stable at 122/85 mmHg. Although he is alert, his family reports a change in his mood and behavior. Abdominal examination reveals general tenderness and ascites. Based on these findings, what is the severity of this patient’s hepatic encephalopathy?