Archives: MRCP Part 2

MRCP2-1918

A 46-year-old woman with a medical history of diabetes, primary biliary cholangitis, and a previous episode of variceal hemorrhage is brought to the resuscitation room in a comatose state. Her husband reports that she has been increasingly confused over the past few days. She takes ursodeoxycholic acid, metformin, and aspirin, but does not consume alcohol or illicit drugs. On examination, she is unresponsive and in a decorticate position with upgoing plantars. There is no meningism, and her pupils are equal and reactive. Her bedside blood glucose is 6.1 mmol/l. Initial blood tests reveal low hemoglobin, platelets, and potassium levels, as well as elevated white cell count, prothrombin time, urea, and C-reactive protein. Her bilirubin and alkaline phosphatase levels are slightly elevated, while her albumin, AST, and ALT levels are within normal range. CT brain shows mild atrophy, and EEG shows diffuse symmetrical triphasic sharp waves. A full sepsis screen is sent to the lab. The patient is intubated for airway protection. How should this patient be further managed?

MRCP2-1919

A 52-year-old man visits his primary care physician complaining of worsening symptoms of oesophageal reflux over the past four years. He denies any difficulty swallowing or weight loss. He has a history of smoking five cigarettes per day and consuming three bottles of wine per week. A routine endoscopy reveals severe Barrett’s oesophagus with high-grade dysplasia. What is the most suitable course of action?

MRCP2-1920

A 35-year-old woman presents to the Emergency Department with fever, nausea, and pain in the right upper quadrant. She recently returned from a trip to India where she volunteered at a rural health clinic. She has a history of occasional alcohol use and does not smoke. On examination, she has a temperature of 38.5 ºC and tenderness over the right upper quadrant. Ultrasound reveals a 7 cm unilocular, unechoic cystic lesion with a double-line sign in the right lobe of her liver. Serology for Echinococcus granulosus is positive (1:320), and you diagnose her with hydatid liver disease. What is the optimal management plan for this patient?

MRCP2-1921

A 45-year-old man with a history of chronic liver disease due to alcohol consumption is admitted to the hospital with confusion. He is currently taking spironolactone 400 mg and furosemide 40 mg along with various vitamin supplements. On examination, there are signs of chronic liver disease and shifting dullness is present. His pulse rate is 102 beats per minute and blood pressure is 95/40 mmHg. Blood tests reveal hyponatremia with a sodium level of 118 mmol/L (137-144). According to the guidelines from the British Society of Gastroenterology on ascites management, what is the most appropriate approach to managing this patient’s hyponatremia?

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?