Archives: MRCP Part 2

MRCP2-2055

A 38-year-old female presents with subacute onset, itching, severe abdominal pain and distension. The patient has a history of hypothyroidism and borderline type 2 diabetes. She occasionally experiences lower back pain following long days standing at work as a waiter. Her current medications include Levothyroxine, Metformin, combined oral contraceptive pill, Paracetamol, and Ibuprofen. On examination, the patient has obvious pain, yellowing of the sclera, and tender hepatomegaly with shifting dullness. Blood investigations reveal elevated levels of Total Bilirubin, ALT, and ALP. Which investigation is most appropriate to confirm the likely diagnosis?

MRCP2-2056

A 52-year-old man presents to the emergency department with a 1-week history of increasing abdominal distention. He has recently been referred to the liver team by his GP following some derangement of his liver function tests performed in a routine Wellman health check. He reports some sporadic right upper quadrant pain but denies any fever or jaundice. He drinks no alcohol and takes no regular medications. There is no family history of note.

What is the most probable reason for this patient’s current clinical presentation based on his test results?

MRCP2-2057

A 40-year-old man presents to gastroenterology clinic with abnormal liver function tests. He reports feeling increasingly lethargic and experiencing intermittent joint pains. His past medical history is significant for a laparoscopic cholecystectomy and borderline diabetes. He has a family history of liver disease but is a former smoker and occasional alcohol consumer. Examination reveals possible spider naevi on his chest but no hepatomegaly or splenomegaly. Investigations show elevated ALT, bilirubin, ferritin, and transferrin saturation, as well as a homozygous C282Y mutation in the HFE gene. What is the appropriate initial management for this patient?

MRCP2-2058

A 50-year-old man comes to the Emergency department complaining of passing dark, black stools for the past two days. He reports unintentionally losing 3 kilograms over the last three months and experiencing alternating diarrhoea and constipation. Upon examination, his blood tests show a haemoglobin level of 62 g/L (130-180), a white cell count of 12.3 ×109/L (4-11), a platelet count of 531 ×109/L (150-400), and an MCV of 75 fL (80-96). An upper gastrointestinal endoscopy does not reveal any cause for the bleeding. What is the next most appropriate diagnostic investigation?

MRCP2-2059

A 26-year-old Greek man presented after his partner reported a personality change over the past four weeks. She reported that he had been very low in mood, and had been behaving strangely. He reported being a little fatigued over the past few weeks. Neurological examination was unremarkable other than a rest tremor in his right hand. There was evidence of scleral icterus, and the liver edge was just palpable below the costal margin.

Initial blood results are shown below:

Haemoglobin 98 g/L
Platelets 156 x 10^9/l
Mean corpuscular volume 89 fl
White cell count 6.8 x 10^9/l
Reticulocyte count 5%
Alkaline phosphatase 142 U/L
Bilirubin 55 mol/L
Alanine transaminase 105 U/L
Albumin 35 g/L

What investigation is most likely to reveal the underlying cause of his anaemia?

MRCP2-2060

A 16-year-old female presents with recent onset of yellowing of the skin, myalgia, and fatigue. She has no significant medical history, drinks ten units of alcohol per week, and denies any high-risk behavior. On examination, she has a tender hepatomegaly and clinical jaundice. The following blood tests were obtained in the acute medical unit:

– Hemoglobin: 123 g/L
– White cell count: 10.0 x 10^9/L
– Neutrophils: 7.0 x 10^9/L
– Platelets: 358 x 10^9/L
– Bilirubin: 85 µmol/L
– Aspartate transaminase (AST): 140 U/L
– Alanine aminotransferase (ALT): 180 U/L
– Alkaline phosphatase: 120 U/L
– Albumin: 36 g/L
– Anti-nuclear antibody (ANA): positive
– Anti-Liver Kidney Microsomal-1 antibody (anti-LKM-1): positive
– Anti-mitochondrial antibody: negative
– Hepatitis B surface antigen (HBsAg): negative
– Hepatitis B surface antibody (anti-HBs): positive
– Hepatitis B core antibody (anti-HBc): negative

What is the most likely diagnosis?

MRCP2-2061

An 80-year-old man presents to his GP with complaints of fatigue and epigastric pain that have been progressively worsening over the past 9 months. The pain is diffuse, intermittent, and rated 4 out of 10 in intensity. He reports passing dark stools and appears pale.

During examination, his blood pressure is 120/70 mmHg, and his pulse is 75/min. There is tenderness in the epigastric region. Upper GI endoscopy reveals a mass in the gastric antrum, and a biopsy of the mass shows infiltrates of lymphoid cells. A CT scan of the chest and abdomen shows normal lymph nodes.

What is the most appropriate management for this patient?

MRCP2-2062

A 27-year-old primigravida woman presents to the hospital at 18 weeks gestation with increasing confusion. Her husband reports that she has been experiencing severe vomiting for the past 4 weeks, making it difficult for her to eat but she has been able to consume small amounts of fluids.

The patient has no significant medical history and is not taking any regular medications.

Upon examination, she is afebrile with a pulse of 110 bpm and blood pressure of 105/70 mmHg. She is alert but disoriented to time and place. Cranial nerve examination reveals bilateral VIth nerve palsy and multi-directional nystagmus. Peripheral neurological examination shows MRC grade 4/5 power in both lower limbs, absent lower limb jerks, bilateral loss of distal vibration sense, and downgoing plantar responses.

Blood tests are ordered and show the following results:

Hb 118 g/l Na+ 133 mmol/l
Platelets 360 * 109/l K+ 2.9 mmol/l
WBC 12.5 * 109/l Urea 9.1 mmol/l
Neuts 10.3 * 109/l Creatinine 115 µmol/l
Lymphs 1.8 * 109/l CRP 18 mg/l
Eosin 0.02 * 109/l Glucose 3.2 mmol/l

What is the most appropriate course of treatment for this patient?

MRCP2-2063

A 42-year-old male presents to the gastroenterology clinic after being referred by his primary care physician. The patient reported experiencing persistent loose stool and mild fatigue. He is a non-smoker and his alcohol intake is within the recommended weekly limit. During the physical examination, the GP noted mild jaundice and mild hepatomegaly, but no other signs of chronic liver disease. The patient underwent a non-invasive liver screen (NILS) prior to being referred to the clinic, which revealed abnormal results. The patient’s laboratory results showed an elevated bilirubin level, high ALP, and positive anti-nuclear antibodies. The abdominal ultrasound showed mild hepatomegaly. Based on these findings, what is the most likely diagnosis?

MRCP2-2064

A 44-year-old man presents to the hospital after experiencing a first episode of syncope. His wife witnessed him suddenly becoming very pale and collapsing to the floor with loss of consciousness for a few seconds, but he immediately regained orientation upon waking up. The patient reports progressively worsening exertional dyspnoea and fatigue over the last few months. He also has been experiencing severe joint pains that have spread to involve other joints. On examination, he is dyspnoeic on minimal exertion, has an irregularly irregular pulse, and peripheral oedema. Investigations reveal abnormal glucose levels, widespread T-wave inversion on ECG, and cardiomegaly with pulmonary oedema on CXR. Which further investigation would be the most useful in confirming the diagnosis?