A 28-year-old woman from Iran presents with recurrent and painful mouth ulcers. She has a history of deep vein thrombosis and experiences intermittent abdominal pain and bloating. On examination, she appears pale and slim with multiple round greyish ulcers in her oral cavity. Her blood tests reveal a haemoglobin level of 102 g/L (115-165), a white cell count of 7.2 ×109/L (4-11), platelets of 387 ×109/L (150-400), a mean corpuscular volume of 68 fL (80-96), and folate levels of 8.2 ng/mL (2.0-11.0) and B12 levels of 301 pg/mL (160-760). What is the most likely underlying diagnosis?
MRCP2-2040
A 19-year-old migrant from Syria comes to you after recently being granted asylum. He is alone in the country and has been experiencing severe burning pain and tingling in his hands and feet for as long as he can remember, especially after exertion or extreme temperatures. He also recalls a brief episode of slurred speech and right facial droop that lasted less than 24 hours. He has never sought medical attention for these issues. During the physical exam, you notice a rash of blue-black telangiectasia on his trunk and hear a mid-systolic murmur that is loudest in the apex and radiates into the axilla. The rest of the exam is unremarkable. He mentions that his younger brother, who passed away some years ago, had similar symptoms, while his sister, whom he has lost touch with, did not. Which of the following findings is indicative of the underlying diagnosis?
MRCP2-2041
A 47-year-old man with a long history of Crohn’s disease is seen in gastroenterology clinic. He was initially diagnosed 14 years ago after presenting with a perianal fistula and abscess, which required emergency surgery and treatment with intravenous corticosteroids. Azathioprine was subsequently used to maintain remission. The patient has experienced disease flares less than every 2 years, which cause severe bloody diarrhea. Colonoscopies performed during exacerbations show colonic inflammation consistent with Crohn’s disease.
During routine monitoring, the patient’s liver function tests were found to be abnormal, leading to further investigations. He was started on cholestyramine and vitamin supplementation after a diagnosis of multiple intrahepatic bile duct strictures and beading was made through endoscopic retrograde cholangio-pancreatogram. The patient expressed concern about his risk of bowel cancer and the need for regular endoscopic surveillance.
What is the appropriate frequency of surveillance colonoscopy for this patient?
MRCP2-2042
A 22-year-old female presents with crampy right iliac fossa pain and diarrhoea. During colonoscopy, moderate ileocaecal disease is observed, characterized by linear ulcerations and patchy erythema. After responding well to oral prednisolone, she is discharged with follow-up. However, upon tapering the steroid dose, she experiences worsening abdominal pain and increased diarrhoea frequency. A blood test is performed by her gastroenterologist, revealing a TPMT level of <10Mu/L (normal range 68-150 mu/L). What is the next best treatment option to offer?
MRCP2-2043
A 32-year-old male presents to the Emergency department with abdominal pain and distension. He admits to significant alcohol excess, drinking at least half a bottle of spirits per day.
On examination he is jaundiced with numerous spider naevi. He is tremulous. His abdomen is grossly distended and shifting dullness is present, no organomegaly can be palpated.
His blood tests reveal: Haemoglobin 113 g/L (130 – 180) White cell count 14.7 ×109/L (4 – 11) Platelets 102 ×109/L (150 – 400) Bilirubin 56 µmol/L (1 – 22) ALP 213 IU/L (45 – 10) ALT 34 IU/L (5 – 35) AST 80 IU/L (1 – 31) Amylase 220 IU/L (60 – 180) Albumin 27 gl/L (37 – 49) C reactive protein 63 mg/L (<10) INR 1.5 (< 1.4)
An ascitic tap is performed and 50 mls of clear yellow fluid are easily aspirated from the abdominal cavity. Analysis of the fluid demonstrates that: Fluid white cell count 670 cells/mm3 65% neutrophils Red cell count 1,684/mm3 Albumin 18 g/L Amylase 732 IU/L Lactate dehydrogenase 139 IU/L
What is the most likely cause of his ascites?
MRCP2-2044
A 50-year-old man presents to the emergency department with a 2-week history of feeling generally unwell. He is a known alcoholic and reports consuming around 1L whiskey per day for the last two months. On further questioning, he reports progressive shortness of breath with some dizziness and palpitations but denies any haematemesis or melaena. He has had no chest or abdominal pain. He states that he takes no regular medications and aside from alcohol dependency has no other medical problems.
Examination reveals scleral icterus but no asterixis and unremarkable respiratory and cardiovascular systems with some right upper quadrant tenderness on abdominal assessment.
Bloods are performed and demonstrate:
Hb 80 g/L Male: (135-180) Female: (115 – 160) Platelets 112 * 109/L (150 – 400) WBC 10.1 * 109/L (4.0 – 11.0) Reticulocytes 5% (0.5 – 2.5%) LDH 500 u/L (140 – 280) Na+ 140 mmol/L (135 – 145) K+ 5.0 mmol/L (3.5 – 5.0) Urea 1.5 mmol/L (2.0 – 7.0) Creatinine 70 µmol/L (55 – 120) Bilirubin 35 µmol/L (3 – 17) ALP 150 u/L (30 – 100) ALT 50 u/L (3 – 40) Triglycerides 5.6g/dL (<1.7)
Blood film polychromasia, macrocytosis, teardrop cells, spur cells and schistocytes
An ultrasound abdomen shows steatohepatitis and splenomegaly.
Endoscopic examination of the upper and lower gastrointestinal systems shows no signs of active bleeding with no varices.
What is the underlying diagnosis?
MRCP2-2045
A 45-year-old teacher presents with a prolonged history of abdominal discomfort and diarrhoea. She was diagnosed with irritable bowel syndrome a decade ago and is currently taking mebeverine, peppermint tablets and a combination of sodium alginate, calcium carbonate and sodium bicarbonate. She is a vegetarian and rarely consumes alcohol or tobacco. Upon examination, all systems appear normal. However, her blood tests indicate macrocytic anaemia. An upper gastrointestinal endoscopy reveals oesophagitis, hypertrophy of the gastric body and multiple duodenal ulcers. What is the most probable diagnosis?
MRCP2-2046
A 75-year-old woman presents with two episodes of ‘black watery diarrhoea’ and a loss of consciousness for 5 minutes in the ambulance on the way to the hospital. She has a medical history of hypertension, arthritis, and gastritis. On examination, she is alert with a heart rate of 80 bpm, blood pressure of 126/76 mmHg, and respiratory rate of 18 breaths per minute. Her abdomen is soft with a mildly tender epigastrium. Rectal examination reveals no melena or bleeding. Laboratory results show normal INR, CRP, and liver function tests, but a low hemoglobin level of 116 g/l.
Based on the NICE guidelines, when should an oesophageal-gastro-duodenoscopy (OGD) be performed for this patient?
MRCP2-2047
An 80-year-old female presents with shortness of breath and difficulty performing daily activities without becoming breathless. She reports worsening breathlessness when lying flat and increased leg swelling. Her medication history includes ramipril and bisoprolol, and she drinks four units of whisky per week. On examination, she has crepitations in her midzones, raised JVP, pulsatile hepatomegaly, and pitting edema to the knees. Her blood pressure is 95/65 mmHg, and heart rate is 95 beats per minute. The diagnosis is pulmonary edema, and she responds well to IV furosemide. Blood results prior to discharge show deranged liver function tests. What is the most likely cause of this?
A 55-year-old male with chronic hepatitis B infection presents to the Emergency Department with increasing confusion. His wife states that his specialist has not started him on antivirals yet. He was diagnosed eight months ago. His past medical history includes tuberculosis that has been successfully treated 12 years ago.
His wife stated also that he slept more than usual in the last week and he was more lethargic. On examination the patient was confused, disoriented with a yellowish discoloration of his eyes. There is moderate peripheral oedema and moderate ascites with no signs of hepatomegaly.
Blood investigations were as follows:
Hb 102 g/l Platelets 250 * 109/l WBC 9.5 * 109/l Bilirubin 42 µmol/l ALP 135 u/l ALT 370 u/l γGT 70 u/l Albumin 32 g/l α-fetoprotein 15 kU/l
What is the most likely cause of this presentation?