Archives: MRCP Part 2

MRCP2-1941

A 40-year-old banker with a history of heart attack and poor glycaemic control is referred by his general practitioner due to abnormal liver function tests. He is currently taking metformin, atenolol, and atorvastatin, drinks socially, and smokes 10 cigarettes per day. On examination, he is overweight and has an enlarged, non-tender liver. An ultrasound scan shows a generalised, hyper-echogenic appearance with no focal lesions. His blood tests reveal elevated levels of ALT, AST, and ALP. What is the most likely diagnosis for this patient?

MRCP2-1942

You evaluate a 27-year-old female patient at the gastroenterology clinic who has previously received treatment for Helicobacter pylori (H. pylori) with omeprazole, amoxicillin, and clarithromycin. Despite being on PPI therapy, she still experiences epigastric discomfort, leading you to suspect that she may have an ongoing H. pylori infection. What is the estimated sensitivity of urea breath testing for the diagnosis of H. pylori?

MRCP2-1943

A 35-year-old pregnant woman presents to the GP with jaundice and itchy skin for the past 2 weeks. She claims that is a lot worse during this pregnancy compared to her last one. History reveals that she is currently 30 weeks pregnant with no complications up until presentation.

On examination, the only notable findings are mild jaundice seen in the sclerae, as well as excoriations around the umbilicus and flanks. She denies any tenderness in her abdomen during the examination. Blood tests show the following:

ALT 206 U/L
AST 159 U/L
ALP 796 umol/l
GGT 397 U/L
Bilirubin (direct) 56 umol/L
Bile salts 34 umol/L

Bile salts reference range 0 – 14 umol/L

What is the most likely diagnosis?

MRCP2-1944

A 55-year-old woman is experiencing intermittent dysphagia and has had a normal upper gastrointestinal endoscopy. She undergoes oesophageal manometry and some of the results are outlined below. She has symptoms of Raynaud’s, and some skin thickening over her hands, but no other significant medical problems. What is the most probable diagnosis based on the following results?

Investigation Result Normal values
Lower oesophageal sphincter resting pressure 8 mmHg 17 – 36 mmHg
Residual lower oesophageal sphincter relaxing pressure 7 mmHg < 8 mmHg
Peristalsis:
Investigation Result Normal values
Proximal amplitude 80 mmHg 33 – 91 mmHg
Distal amplitude 25 mmHg 64 – 154 mmHg

MRCP2-1945

A 35-year-old woman presents to the Emergency Department with a complaint of chest discomfort. She reports a burning sensation behind her breastbone that is triggered by heavy meals and worsens when lying down. She denies any difficulty swallowing, nausea, vomiting, or vomiting blood. Her bowel movements are regular, and she has not experienced any black, tarry stools. She has no significant medical history or family history. She drinks alcohol occasionally.
Upon examination, she appears comfortable, with a regular pulse of 80 bpm. Her heart sounds are normal, and her lungs are clear. Her abdomen is soft and non-tender, with no palpable masses or enlarged organs. Bowel sounds are normal, and a rectal exam reveals no blood, black stools, or masses. Routine blood tests, including a complete blood count, are normal. She plans to reduce her alcohol consumption.
What is the most appropriate course of action for managing this patient?

MRCP2-1946

A 45-year-old man with chronic liver disease due to chronic hepatitis B infection presents with ascites and jaundice. He denies any history of alcohol consumption. He has known oesophageal varices. On examination, he appears a little drowsy with a grossly distended and ascitic abdomen. His blood tests reveal low platelets, elevated bilirubin, and elevated INR. He is also experiencing back pain. What is the safest analgesic agent to prescribe for him?

MRCP2-1947

An 80-year-old man presents with jaundice. He is a heavy drinker, consuming approximately 30-35 units per week. There is no history of abdominal pain, and pain is not elicited on abdominal examination. However, examination does reveal a palpable gallbladder. Bloods are taken and the results are:

Albumin 28 g/L
Alk Phos 320 U/L
ALT 90 U/L
Bilirubin 98 mol/L
INR 1.5
GGT 120 U/L

What is the likely diagnosis for this patient?

MRCP2-1948

A 42-year old teacher is brought to the Emergency Department after having taken 30 paracetamol tablets with a bottle of wine 6 hours prior to admission, following a stressful day at work. She feels dizzy and complains of stomach pain. There is no past medical history of note and she takes occasional aspirin tablets. She drinks about 10 units of alcohol per week. Physical examination is normal.

Investigations:
Sodium (Na+) 138 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5 – 5.0 mmol/l
Urea 4.5 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 70 µmol/l 50 – 120 µmol/l
Bicarbonate (HCO3-) 22 mmol/l 22 – 29 mmol/l
International normalized ratio (INR) 1.0 < 1.1
Serum ibuprofen level 300 mg/l 100 – 200 mg/l

Which of the following is the most useful prognostic indicator when tested the next day?

MRCP2-1916

A 23-year-old recent graduate presents to the clinic complaining of fatigue, yellowing of the skin and eyes, and difficulty eating due to a sore throat. She recalls that her mother had a liver condition. On examination, she has a fever of 38.5 °C, blood pressure of 120/80 mmHg, and a regular pulse of 90/min. Pharyngitis is noted on examination of her throat. Laboratory tests reveal the following results:

– Alanine aminotransferase (ALT): 25 u/l (normal range: 7-55 u/l)
– Aspartate aminotransferase (AST): 30 u/l (normal range: 10-40 u/l)
– Bilirubin: 85 μmol/l (normal range: 1-22 μmol/l)
– Albumin: 38 g/l (normal range: 35-55 g/l)

What is the most appropriate next step in the management of this patient, given the most likely diagnosis?

MRCP2-1917

A 55-year-old man with a history of alcoholic liver disease presents with confusion on the ward. Upon examination, he has a heart rate of 100 beats per minute and stable blood pressure at 122/85 mmHg. He appears drowsy and confused, with ascites and general abdominal tenderness. Asterixis is also present. The diagnosis is hepatic encephalopathy caused by spontaneous bacterial peritonitis. Which of the following management steps is the least appropriate for this patient?