A 57-year-old male presents to his primary care physician with worsening pruritus, which he finds embarrassing at work. He has a past medical history of hypertension and mild osteoarthritis. He takes lisinopril for his blood pressure. He drinks on average two beers a night.
During the physical examination, he has mildly jaundiced sclera, xanthelasma, clubbing, and hepatomegaly. His blood pressure is 150/90 mmHg, pulse is 80/min and regular, and his BMI is 27.
Which of the following tests is most likely to be elevated/abnormal given the probable clinical diagnosis?
MRCP2-2069
A 52-year-old French farmer presents to your clinic after his GP discovered mildly abnormal LFTs during a routine check-up. He denies any changes in bowel habits or abdominal pain, and on examination, you note mild scleral icterus.
His vital signs are as follows: blood pressure 128/70 mmHg, heart rate 68 bpm, respiratory rate 16/min, pulse oximetry 98%, temperature 37.1ºC.
A liver ultrasound reveals a cyst with a ‘sand sign’, and a CT abdomen confirms the presence of a 5cm cyst in the right lobe of the liver with two smaller cysts measuring 1 cm in diameter at the periphery.
Which diagnostic test would be most helpful in confirming the diagnosis?
MRCP2-2070
A 25-year-old male patient complains of abdominal bloating and diarrhoea that has been ongoing for four months. He reports having bowel movements 2-3 times a day and recurrent aphthous ulcers, but denies experiencing weight loss or passing mucus or blood in his stools. The patient has not traveled in the past year and has no family history of inflammatory bowel disease. Upon examination, his abdomen was soft with no organomegaly. Coeliac serology results were negative. What is the next recommended test?
MRCP2-2071
A 25-year-old student presented with a tremor in his left arm. He had also noticed increasing difficulty with speech, clumsiness in both hands and unsteadiness walking. He reported being very stressed and anxious. His relationship with his long-term girlfriend had come to an end and his younger sister had recently been diagnosed with bipolar affective disorder.
This student had a past medical history of depression and was born prematurely at 30 weeks gestation requiring ventilatory support in the neonatal intensive care unit. He took no regular medications and denied recreational drug use. He was, however, a binge drinker, consuming at least 25 units of alcohol per week. He had a penicillin allergy.
On examination there was a bilateral resting tremor more marked in the left arm than the right. The tone of the left arm was slightly increased. The movements of his upper limbs and hands were slow with reduced dexterity although there was no weakness. Reflexes were present and symmetrical. There was no sensory disturbance. On walking this patient had a broad-based, slow, ataxic gait with small steps. Romberg’s test was negative. Power, tone, reflexes and sensation in the lower limbs were normal.
Investigations:
Hb 11.5 g/dl Platelets 120 * 109/l WBC 9.5 * 109/l International Normalised Ratio 1.2
Bilirubin 75 µmol/l ALP 200 u/l ALT 90 u/l Amylase 70 u/l
Given the most likely underlying diagnosis which of the following would be the most appropriate management plan?
MRCP2-2072
A 35-year-old man visited a medical clinic for the first time. He had been experiencing recurrent abdominal pain that improved with defecation, and mushy stools up to three times a day for the past 5 months. He denied any weight loss, rectal bleeding, or a family history of colorectal cancer. Stool microscopy, culture and sensitivity tests were negative for ova, cysts, and parasites.
What is the most suitable next step in investigating this patient’s condition?
MRCP2-2073
You are requested to assess a 67-year-old female patient who has been admitted to the ward. The nursing staff is concerned about her constipation as she has not had a bowel movement in four days. The patient has a medical history of hypertension and is currently hospitalized due to a urinary tract infection. During the examination, you notice that her abdomen is distended and there is mild tenderness in the lower abdomen. However, the patient reports passing flatus regularly.
You order an abdominal x-ray which shows dilated small loops of bowel with no visible transition point. There is visible gas in the rectum.
What is the most appropriate antiemetic for this patient?
MRCP2-2074
A 56-year-old female nurse experiences a needlestick injury while administering medication to a patient. The patient has a history of blood transfusions, but there is no known history of infectious diseases. The nurse has a past medical history of hypertension and diabetes. She recently moved from Mexico and is uncertain if she has been vaccinated for hepatitis B.
A 36-year-old ex intravenous drug user has been diagnosed with HBe-Ag positive Hepatitis B. Her investigation results are as follows:
– HBV DNA 2100 IU/ml – ALT 60 IU/L
The patient’s ALT was last checked 3 months ago and was found to be 60 IU/L. What is the recommended initial treatment for this individual?
MRCP2-2076
A 54-year-old man has undergone a colonoscopy due to per rectal bleeding and was found to have two small adenomas measuring less than 10mm. He has no significant medical history and no family history of colorectal cancer. What is the most appropriate approach for colonoscopic monitoring in this individual?
MRCP2-2077
A 72-year-old patient presents to the emergency department with a four-day history of diffuse diarrhoea. The patient has a medical history of hypertension and type 2 diabetes and is currently taking amlodipine and metformin. The patient was recently treated with co-amoxiclav for a lower respiratory tract infection. On examination, there is mild generalized abdominal tenderness without peritonism. The patient’s observations are heart rate 105 beats per minute, blood pressure 88/62 mmHg, respiratory rate 19/minute, oxygen saturations 97% on room air, and temperature 38.2.
The patient is started on intravenous fluids and the following results are obtained: Hb 138 g/L (Male: 135-180, Female: 115-160), platelets 412 * 109/L (150-400), WBC 15.4 * 109/L (4.0-11.0), Na+ 131 mmol/L (135-145), K+ 4.2 mmol/L (3.5-5.0), urea 8.2 mmol/L (2.0-7.0), creatinine 88 µmol/L (55-120), and CRP 44 mg/L (<5). A CT abdomen and pelvis is arranged, which shows severe colitis with a transverse colon diameter of 4cm. A stool sample demonstrates Clostridium difficile toxin.
What is the appropriate management for this patient?