Archives: MRCP Part 2

MRCP2-1953

A 45-year-old man presents with complaints of epigastric pain. He has a history of occasional alcohol consumption and smoking 20 cigarettes a day. Despite being generally healthy, he has been experiencing back pain and has been taking ibuprofen for the past few months. Additionally, he has been under significant stress and has had to take time off work.

During examination, the patient is stable but experiences tenderness in the epigastric region. His GP prescribed omeprazole 40 mg od, which he has been taking regularly for the past month. While the medication has provided some relief, he has not experienced complete resolution of his symptoms. An endoscopy is scheduled, which reveals duodenal ulceration.

What is a characteristic clinical feature of a duodenal ulcer?

MRCP2-1954

A 56-year-old man with a history of Crohn’s disease presents with a complaint of fatigue for the past year. Recently, he has been experiencing muscle pain and weakness, as well as multiple falls.

During the examination, the patient appears thin and pale. His heart rate is 85 beats per minute, and his blood pressure is 130/80 mmHg. His chest is clear, and his heart sounds are normal. However, his abdomen has a laparotomy scar. Neurological examination reveals bilateral foot drop, reduced ankle jerks, widespread muscle wasting, and calf fasciculations. Additionally, he has reduced pinprick sensation to mid-shin.

Blood tests show:

– Hb: 144 g/l
– Platelets: 195 * 109/l
– WBC: 6.3* 109/l
– Na+: 137 mmol/l
– K+: 4.5 mmol/l
– Urea: 7 mmol/l
– Creatinine: 91 µmol/l
– Corrected calcium: 2.5 mmol/l
– HbA1c: 45 mmol/mol

What is the likely diagnosis?

MRCP2-1955

A 65-year-old female patient with a history of long term rheumatoid arthritis is experiencing increasing shortness of breath on exertion while receiving etanercept. She has previously been treated with methotrexate but had to discontinue due to recurrent infections. On examination, she has a blunted affect, a mildly swollen and red tongue, and brittle nails. Basic investigations including blood tests and a chest x-ray were performed, with normal results. What is the probable diagnosis?

MRCP2-1956

You evaluate a 32-year-old female patient in the gastroenterology clinic who has a history of Peutz-Jeghers syndrome and has been receiving regular colonoscopy surveillance. What is the recommended frequency for colonoscopy screening in this patient?

MRCP2-1957

A 57-year-old male presents to the clinic with a 6 month history of progressive nausea and lethargy. He has a past medical history of poorly controlled diabetes. During examination, you observe jaundiced sclera and moderate ascites. He consumes approximately 20 units of alcohol per week.

The investigation results are as follows:

Hb 125 g/l
Na+ 138 mmol/l
Bilirubin 96 µmol/l
Platelets 355 * 109/l
K+ 3.8 mmol/l
ALP 110 u/l
WBC 9.6 * 109/l
Urea 6.8 mmol/l
ALT 210 u/l
Neuts 6.4 * 109/l
Creatinine 76 µmol/l
AST 95 u/l
Lymphs 3.1 * 109/l
Albumin 28 g/l
Eosin 0.1 * 109/l

An enhanced liver fibrosis (ELF) test was conducted, and the results showed an enhanced liver fibrosis score of 11.62 (high).

As per current guidelines, what treatment will you consider prescribing to prevent further liver fibrosis, given the patient’s condition?

MRCP2-1958

A 56-year-old Caucasian female presents with a 4-month history of difficulty swallowing bread and solid meats, but no issues with liquids. She has unintentionally lost around 2 stones in weight during this time. There are no reports of night sweats or fevers, haematemesis, changes in bowel habits, or melaena. She reports no changes in her voice or episodes of aspiration. During examination, koilonychia and an enlarged tongue with conjunctival pallor are observed. Her blood test results are as follows:

– Hb: 76 g/l
– MCV: 62 fl
– Platelets: 246 * 109/l
– WBC: 7.2 * 109/l
– Ferritin: 22 ng/ml
– Na+: 142 mmol/l
– K+: 4.2 mmol/l
– Urea: 5.6 mmol/l
– Creatinine: 55 µmol/l
– CRP: 20 mg/l

Her GP refers her for an urgent upper oesophageal-gastric endoscopy (OGD) as part of the 2-week wait of suspected cancer. During the OGD, a narrowed distal oesophageal lumen caused by webs that are ruptured as the scope is passed is observed. What is the most likely diagnosis?

MRCP2-1959

A 50-year-old man presents with lower back pain, fatigue, weight loss, and tingling in his hands and feet. On examination, he has gynaecomastia, a palpable liver edge, peripheral edema, loss of pinprick and joint position sense to the mid-shins bilaterally, and diffuse hyperpigmentation of the extremities. His lab results show low hemoglobin, low albumin, high fasting glucose, and elevated TSH with low T4. What is the most likely diagnosis for this patient’s symptoms?

MRCP2-1960

A 35-year-old drug abuser is referred to the Rheumatology Clinic for evaluation. He has been experiencing intermittent fevers, joint and muscle pains, and a skin rash over the past few months. He admits to continued use of intravenous cocaine over the past five years.
Other past history of note includes an episode of right ulnar nerve palsy some 8 months earlier. His only medication is over-the-counter pain relievers.
On examination, his blood pressure is 140/90 mmHg, with a pulse of 85/min and regular. He has an erythematous skin rash and you notice some spider naevi on examination of the upper body.
Investigations:
s
Haemoglobin (Hb) 112 g/l 135 – 175 g/l
White cell count (WCC) 9.8 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 130 × 109/l 150 – 400 × 109/l
Sodium (Na+) 138 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 120 µmol/l 50 – 120 µmol/l
Erythrocyte sedimentation rate (ESR) 70 mm/h 1 – 20 mm/h
Urine blood ++ protein + No RBC cast
HepBsAg +
HepBeAg +
HepBsAb -ve
HepBcAb +
What is the most likely diagnosis for this patient?

MRCP2-1961

A 57-year-old male with metastatic oesophageal cancer on palliative chemo presents with worsening nausea and vomiting despite antiemetic treatment. He reports vomiting after eating and occasionally regurgitating formed parts of meals. A diagnosis of oesophageal obstruction due to tumour invasion is made and he undergoes successful stenting before being discharged with a nasogastric feeding plan.

However, one week later, he returns to the emergency department with dysphagia and increased vomiting, including regurgitation of whole food. He claims to have followed the feeding plan except for a small piece of chicken which he insists he chewed thoroughly. Blood tests and chest X-ray are normal. What is the most likely diagnosis?

MRCP2-1962

A 50-year-old woman was referred to a specialist by her doctor due to abnormal liver function tests. She had undergone routine blood tests as part of a diabetes mellitus evaluation. The patient had a medical history of hypertension, type 2 diabetes, hypothyroidism, and pernicious anaemia. She reported occasional pain in the right upper quadrant but denied any symptoms of obstructive jaundice. She did not consume alcohol. The patient was taking aspirin, thiazide, and metformin. On examination, her body mass index was 34, blood pressure was 170/90 mmHg, and her random glucose level was 11.6 mmol/L (3.0-6.0). There were no other abnormal findings.

Haemoglobin: 132 g/L (115-165)
White cells: 9.0 ×109/L (4-11)
Platelets: 350 ×109/L (150-400)
MCV: 92 fL (80-96)
Albumin: 40 g/L (37-49)
Bilirubin: 20 μmol/L (1-22)
Alanine aminotransferase: 105 U/L (5-35)
Aspartate aminotransferase: 50 U/L (5-35)
Alkaline phosphatase: 100 U/L (45-105)
Gamma gluteryltransferase: 40 U/L (<50)
Smooth muscle antibody: Not detected
Anti mitochondrial antibody: Not detected
Serum IgG: 10 g/L (6-13)
Serum IgA: 1 g/L (0.8-3)

What is the probable cause of the liver abnormality?