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?
MRCP2-2065
A 65-year-old man on the gastroenterology ward experiences an acute episode of haematemesis during the night. The nurse who witnessed the event reported that the bleed was approximately one cupful of bright red blood. The patient has a history of heavy alcohol consumption, drinking 2 bottles of whiskey a day, and has a past medical history of ascites secondary to alcoholic liver cirrhosis, hypertension, and type two diabetes mellitus. He was admitted initially for an ascitic drain earlier in the afternoon, which has not occurred due to staff shortages in the medical team.
Upon examination, the patient was afebrile, with a heart rate of 110 bpm, blood pressure of 104/81 mmHg, respiratory rate of 20 breaths per minute, and an oxygen saturation of 97% on air. Cardiovascular and respiratory examination was unremarkable. Abdominal examination revealed a tensely distended abdomen with shifting dullness present. There were marked distended superficial veins on his abdominal surface. There was mild epigastric tenderness, and on rectal examination, there was a small amount of tarry black stool. He was not actively vomiting during the examination.
The house officer on call had already started intravenous fluid resuscitation, and blood samples including a cross-match were sent. The gastroenterology registrar on call has been informed and was arranging an emergency endoscopy for the patient.
His previous blood results and a current venous blood gas (VBG) results are shown:
Blood results (earlier in the afternoon)
Na+ 134 mmol/l K+ 4.8 mmol/l Urea 10.9 mmol/l Creatinine 100 µmol/l Serum bilirubin 30 µmol/l Serum alkaline phosphatase 165 IU/l Serum aspartate aminotransferase 68 IU/l C Reactive protein 6 mg/l Haemoglobin 126 g/l White cell count 7.6 x 10^9/L Platelets 122 x 10^9/L INR 1.8
What is the next most appropriate immediate course of action to take?
MRCP2-2031
A 47-year-old man presents to the gastroenterology clinic with a 7 month history of abdominal pain, diarrhea, and weight loss. His symptoms have been progressively worsening over the past few weeks and he has also been experiencing joint pain in his hands and feet. The abdominal pain is not relieved by defecation and is associated with bloating. He reports a weight loss of approximately 10 kg over the past 7 months.
The patient works in the IT industry and frequently travels to Southeast Asia. He is married and does not smoke. On examination, he has soft and non-tender lymph nodes in the cervical and inguinal regions. His wedding ring is loose and loss of the nail angle is noted. There is mild tenderness in the epigastric region, but no organomegaly or evidence of swelling, erythema, or synovitis in the hands or feet. His pulse, blood pressure, and temperature are normal.
Laboratory results show a hemoglobin level of 10.4 g/dl, platelets of 222 * 109/l, WBC of 6.96 * 109/l, Na+ of 139 mmol/l, K+ of 3.6 mmol/l, urea of 5.1 mmol/l, creatinine of 78 µmol/l, bilirubin of 14 µmol/l, ALP of 120 u/l, ALT of 34 u/l, γGT of 55 u/l, and albumin of 26 g/l.
What is the most appropriate treatment for this patient?
MRCP2-2032
A 50-year-old woman with a family history of haemochromatosis presents to her GP with fatigue. She has no significant medical history and does not drink alcohol. Cardiovascular, respiratory and abdominal examinations are unremarkable. Her BMI is 35 kg/m². Blood tests reveal a positive antinuclear antibody and elevated ferritin and transferrin saturation levels. What is the most likely diagnosis?
MRCP2-2033
A 56-year-old woman presents to her primary care physician with distressing abdominal symptoms. She reports experiencing bloating, abdominal discomfort, diarrhoea, and abdominal distension. Despite trying a gluten-free diet, she has not seen significant improvement. She has a medical history of limited systemic sclerosis and is not currently taking any medications.
During the examination, her abdomen is mildly distended, but otherwise unremarkable. The physician notes skin thickening extending to the dorsum of her hands, as well as microstomia and telangiectasia on her face.
After conducting blood tests, the following results were obtained:
A 25-year-old female patient visits her family doctor with a 5-day history of fever, sore throat, and flu-like symptoms. She has been experiencing difficulty eating for the past few days and is worried because her eyes have turned yellow. She mentions that she has had yellowing of the eyes before but recovered without any issues. During the examination, the doctor observes that the patient is jaundiced. Her serum bilirubin level is 62 µmol/l, while her aspartate transaminase (AST) and alkaline phosphatase (ALP) levels are within the normal range. Her full blood count is normal. What is the most appropriate course of action for this patient?
MRCP2-2035
A 56-year-old man is being assessed on the ward two hours after a liver biopsy. He was admitted three days ago with jaundice and diagnosed with acute hepatitis. He has a medical history of hypertension, anxiety, and cholecystectomy. Despite minimal alcohol intake, an acute liver screen found no clear cause for his hepatitis, leading to the biopsy. During the review, the patient reports severe pain in the right upper quadrant and feeling generally unwell. The nurse observed dark stool, which he believes is indicative of melaena. Upon examination, the patient’s blood pressure is 94/56 mmHg, heart rate is 113/min, oxygenation is 94%, and respiratory rate is 26/min. The patient is jaundiced, has a tender right upper quadrant, and a PR examination reveals melaena. What is the most probable reason for his decline?
MRCP2-2036
A 36 year-old nulliparous woman, who is at 35 weeks gestation, presents with a 10-hour history of fatigue, nausea and vomiting. She has not eaten for the past 24 hours and says that she feels a little dizzy. She describes no blood in her vomit and has had no recent changes in her bowel habit. She has no past medical history of note and she does not currently take any regular medication. She has no family history of note and does not smoke or drink any alcohol.
On examination she appears to be very anxious and abdominal exam reveals right upper quadrant and epigastric pain on deep palpation. There is no organomegaly and bowel sounds are present. The baby is moving normally.
She has a temperature of 37.5oC, heart rate of 85 beats per minute, blood pressure of 135/80 mmHg, oxygen saturation of 99% and a respiratory rate of 18 breaths per minute.
A 54 year-old man presents with a 4 month history of impotence, joint pains and malaise. He has a medical history of type 2 diabetes mellitus and hypertension, and is currently taking metformin, ramipril and amlodipine. He has a 30 pack-year history and drinks 15-20 units per week. He works as a police officer.
During examination, a palpable 2 cm non-tender liver edge is found in his abdomen. Heart sounds 1 and 2 are present with no added sounds, his pulse is regular and his lung fields are clear.
Blood tests reveal:
Bilirubin 20 µmol/l ALP 462 u/l ALT 79 u/l γGT 98 u/l Albumin 37 g/l
What is the most appropriate diagnostic investigation?
MRCP2-2038
A 14-year-old male presents to his GP with a three-month history of yellowing of the eyes. He denies any associated symptoms and is generally in good health. There is a family history of jaundice, but he is unsure which family members are affected and whether they have been investigated. He does not take any regular medications, herbal or over-the-counter remedies, and has not recently taken antibiotics. He is a non-smoker and occasionally drinks up to two pints of beer in an evening. He denies any recreational drug use and reports no sexual activity. He recently traveled to France.
During the clinical examination, scleral jaundice is observed, but otherwise, there are no significant findings.
Routine blood tests are performed, and the results show: