Archives: MRCP Part 2

MRCP2-1922

You review a 46-year-old man in the gastroenterology clinic who has been referred by his GP with abnormal liver function tests. The only past medical history is a recent diagnosis of hypertension.

On direct questioning, he denies alcohol intake or intravenous drug use. There is no travel history.

On examination, he is pale, there is evidence of digital clubbing and he has spider naevi over the anterior chest wall. Abdominal examination reveals tender hepatomegaly 3 cm below the costal margin.

What are the possible management options for this patient’s underlying condition?

MRCP2-1923

A 55-year-old woman presents with a three month history of pruritus and lethargy. She has a history of hypothyroidism and denies regular alcohol intake. On examination, there is evidence of excoriations and xanthelasma. Her blood results show elevated liver enzymes and ALP. Abdominal ultrasound scan is normal. What is the most likely management indicated for this patient?

MRCP2-1924

A 16-year-old boy is brought to the Emergency department by his parents. He has no past medical history of note.

In his parents’ absence, he reveals that he took an overdose of paracetamol after a fight with his girlfriend, but did not intend to end his life.

What is the most reliable indicator of the extent of liver damage?

MRCP2-1925

A 35-year-old man visits his primary care physician with a 4-week history of occasional rectal bleeding. He has noticed blood on the toilet paper a few times while wiping. He is concerned because his father was diagnosed with colon cancer at the age of 60. The patient has no significant medical history but reports chronic constipation since his early 20s.

Upon examination, the patient has a soft and non-tender abdomen. There is no active bleeding or pain during digital rectal examination.

What is the next appropriate step in managing this patient’s condition?

MRCP2-1926

A 70-year-old man is admitted to the hospital from a nursing home due to vomiting and diarrhea. The symptoms started three days ago and have been getting worse. He is passing six to seven green, watery, and foul-smelling stools a day, and is unable to control his bowel movements. He is also vomiting once or twice a day. He has a history of dementia and recurrent urinary tract infections. He is currently taking lansoprazole and donepezil, and has no known allergies.

During the examination, he is found to be malnourished, dehydrated, and afebrile. His abdomen is tender and has increased bowel sounds. Blood tests reveal a high white cell count, high neutrophils, and a high C-reactive protein level. His sodium, potassium, urea, and creatinine levels are also elevated. A plain x-ray of the abdomen shows a featureless transverse and descending colon with mucosal thickening.

What is the most appropriate course of treatment?

MRCP2-1927

A 71-year-old man with a history of atrial fibrillation and bladder cancer with lung metastases presents to the Emergency Department (ED) of a District General Hospital with severe diarrhoea and crampy abdominal pain. He missed a few doses of his apixaban in the last few weeks and has been receiving atezolizumab for his lung metastases. On examination, there is mild tenderness in the left iliac fossa and a DRE reveals mucous and blood mixed with his faeces. Investigations reveal colitis. What is the most appropriate management option for this patient?

MRCP2-1928

A 55-year-old male presents with complaints of general lethargy, weight gain, and abdominal swelling. He reports that his symptoms have been worsening over the past three months and admits to heavy alcohol consumption for a long time. He is not currently taking any medication and has no significant medical history.

During examination, he appears well-oriented, has a normal body temperature, and his blood pressure is 132/88 mmHg. He has multiple spider naevi on his upper chest and gynaecomastia. Abdominal examination reveals moderate ascites, and he has edema in his legs up to the mid-thigh. No organomegaly is noted during abdominal examination.

The following investigations were conducted:
– Serum sodium 140 mmol/L (137-144)
– Serum potassium 4.4 mmol/L (3.5-4.9)
– Serum urea 7.8 mmol/L (2.5-7.5)
– Serum creatinine 135 µmol/L (60-110)
– Serum total bilirubin 35 µmol/L (1-22)
– Serum aspartate aminotransferase 70 U/L (1-31)
– Serum alkaline phosphatase 220 U/L (45-105)
– Serum albumin 30 g/L (37-49)

What would be the most appropriate initial management measure for this patient?

MRCP2-1929

A 47-year-old woman is being admitted for therapeutic ERCP to remove multiple large common bile duct stones. She has a medical history of ischemic heart disease and is currently taking aspirin and clopidogrel for secondary prophylaxis. Additionally, she takes simvastatin, lansoprazole, and bisoprolol, and has no known drug allergies. Based on the 2008 BSG guidelines regarding anticoagulant management during endoscopy, what is the best course of action?

MRCP2-1930

A 35-year-old man presents to the Emergency Department with severe epigastric pain, nausea, and vomiting. You note that he was recently started on medication for epilepsy.
Upon examination, his blood pressure is 110/70 mmHg and his heart rate is 100 bpm regular. He has a mild fever of 37.5 °C. The epigastrium is tender, and he experiences significant pain with minimal palpation.
Laboratory results show:
– Haemoglobin (Hb): 130 g/l (normal range: 135-170 g/l)
– White cell count (WCC): 12.5 × 109/l (normal range: 4.0-11.0 × 109/l)
– Platelets (PLT): 150 × 109/l (normal range: 150-400 × 109/l)
– Sodium (Na+): 140 mmol/l (normal range: 135-145 mmol/l)
– Potassium (K+): 4.2 mmol/l (normal range: 3.5-5.0 mmol/l)
– Creatinine (Cr): 135 μmol/l (normal range: 50-120 μmol/l)
– Corrected calcium (Ca2+): 2.25 mmol/l (normal range: 2.2-2.7 mmol/l)
– Amylase: 950 U/l (normal range: 30-110 U/l)

Which of the following medications is most likely responsible for the patient’s symptoms?

MRCP2-1931

A 49-year-old female presents with severe abdominal pain localized at the top of her abdomen that radiates through to her back. She describes the pain as sharp and excruciating. On examination, she has epigastric tenderness but is haemodynamically stable. Her medical history includes ulcerative colitis and osteoarthritis, and she reports taking an oral medication for inflammatory bowel disease and an over-the-counter medication for arthritis, but cannot recall the specific drugs.

The following blood results were obtained:
– Hb: 136 g/l
– Platelets: 582 * 109/l
– WBC: 18.2 * 109/l
– Neuts: 14.2 * 109/l
– Lymphs: 2.2 * 109/l
– Eosin: 0.2 * 109/l
– Na+: 138 mmol/l
– K+: 3.6 mmol/l
– Urea: 8.6 mmol/l
– Creatinine: 62 µmol/l
– CRP: 52 mg/l
– Amylase: 800 U/L (normal < 160) Which medication is most likely responsible for this patient’s presentation?