A previously healthy 35-year-old man comes to the clinic complaining of watery diarrhea that has persisted for 2 years. He reports that the stool does not float and there is no blood. Tests for fecal occult blood and fecal elastase have been normal. He has been taking lansoprazole for gastroesophageal reflux disease for the past 24 months. Blood tests for endomysial antibody and thyroid function have been normal, but his white blood cell count was slightly elevated at 12.6 × 109/l and erythrocyte sedimentation rate elevated at 32 mm/h. Colonic imaging has not yet been performed. What is the most appropriate next step?
MRCP2-1891
A 67-year-old man has chronic autoimmune hepatitis. He is being treated with prednisone and azathioprine. During a routine check-up, you notice that his jaundice has worsened and his bilirubin levels are increasing. He is admitted to the hospital, and the next morning the nurses call you urgently as he has become increasingly lethargic. His blood pressure is 100/50 mmHg, and he has a fever of 38.2 °C. Which test is most likely to confirm the suspected diagnosis?
MRCP2-1892
A 32-year-old man presents with yellowing of his skin and eyes. He reports feeling fatigued and experiencing abdominal pain. He has no significant medical history and takes no regular medications. On examination, he has jaundice and tenderness in the right upper quadrant of his abdomen. Blood tests reveal the following results:
Bilirubin 45 µmol/l 2–17 µmol/l Alkaline phosphatase (ALP) 150 IU/l 30–130 IU/l Alanine aminotransferase (ALT) 40 IU/l 5–30 IU/l Urine dipstick Normal What is the most likely diagnosis and what further investigations or management should be considered?
MRCP2-1893
A 35-year-old man visits the Gastroenterology Clinic with complaints of alternating episodes of constipation and diarrhea. He reports no significant weight loss and maintains a diverse diet. Upon examination, his blood pressure is 120/80, his heart rate is 70 and regular, and his BMI is 23 kg/m2. A complete blood count and viscosity test reveal no abnormalities. A flexible sigmoidoscopy shows no notable findings. What is the most suitable course of action for management?
MRCP2-1894
The Medical Emergency Team was summoned to the interventional radiology department to assess a 49 year-old teacher who had undergone a liver biopsy. Although the procedure itself was uneventful, the patient suddenly became severely unwell and experienced shortness of breath. The patient had no significant medical history except for ongoing investigations into abnormal liver function tests. He was not taking any medication and had no known allergies. He had not traveled recently, did not smoke, and consumed 12 units of alcohol per week.
Upon examination, the patient was lying flat on the trolley and appeared flushed. His temperature was 36.7ºC, heart rate was 110 beats per minute, blood pressure was 82/40 mmHg, respiratory rate was 28 breaths per minute, and oxygen saturation was 100% on a non-rebreather mask. The chest was clear upon auscultation, and heart sounds were normal. The JVP was not visible. There was mild tenderness in the right upper quadrant upon palpation of the abdomen, but no guarding or rebound tenderness.
The investigations conducted before the biopsy were as follows:
– Haemoglobin 160 g/L (130-180) – White cell count 8.0 * 109/l – Neutrophil count 4.0 * 109/l – Lymphocyte count 3.0 * 109/l – Eosinophil count 0.8 * 109/l – Platelets 350 * 109/l – Sodium 140 mmol/L – Potassium 4.1 mmol/L – Urea 6.5 mmol/L – Creatinine 75 mol/L – Alkaline phosphatase 101 IU/L – Alanine aminotransferase 82 IU/L – Gamma-glutyl transferase 59 IU/L – Bilirubin 18 mol/L – Albumin 36 g/L – Prothrombin time 12 s (10-14) – Activated partial thromboplastin time 38 s (30-45) – Ultrasound abdomen: Hypoechogenic lesion in the right lobe of the liver
What is the most appropriate initial treatment?
MRCP2-1895
A 26 year old man presented to the Emergency Department with acute onset, rapidly progressive weakness in all the four limbs following a bout of severe colicky abdominal pain which lasted for 10 days but eventually subsided. The abdominal pain was located around the umbilicus, stabbing in nature, radiated towards the back, and was associated with nausea and intermittent constipation. Patient reports weakness originating in both arms then affecting both the lower limbs. He also complains of difficulty in closing his lips and eyes, and has uncontrolled salivation from the angles of the mouth. He denied any history of paraesthesia, sphincteric disturbances, epileptic fits or dark colored urine during any of the episodes. No definite history of any drug intake prior to both the episodes could be ascertained.
Physical examination revealed bilateral facial palsy of lower motor neuron (LMN) type together with flaccid quadriparesis which was more marked distally with bilateral wrist drop. Deep tendon reflexes were diminished in both upper and lower limbs. There was no sensory loss.
Initial lab values showed WBCs 8.9×10^9/L, Hemoglobin of 12 g/L, Sodium of 132 mmol/L, and ESR of 35mm/Hr. His temperature was 36.5 C and pulse 83/min. His blood pressure was 130/83 mm/Hg and oxygen saturations were 98% on air. A lumbar puncture was performed and CSF studies were normal.
Which of the following is most likely to be diagnostic?
MRCP2-1896
A 25-year-old man of Gambian descent presents to the hospital with complaints of severe abdominal and back pain. Upon examination, he is found to be jaundiced, but there are no signs of chronic liver disease. His blood tests reveal a low hemoglobin level, normal white cell count, low platelet count, high lactate dehydrogenase level, high bilirubin level, high alkaline phosphatase level, slightly elevated ALT level, normal albumin level, and normal INR. An abdominal ultrasound shows multiple stones in the gallbladder and a thick-walled gallbladder with no evidence of edema or pericholecystic fluid. The common bile duct has a diameter of 7 mm without intrahepatic duct dilatation. Which investigation is most likely to determine the underlying cause of his jaundice?
MRCP2-1897
A 55-year-old male with a long history of cirrhosis secondary to chronic hepatitis C presents to the emergency department with a 2-day history of increasing confusion.
He is drowsy but can be roused to voice. He is able to follow commands but is disoriented to his surroundings. Upon further examination, he exhibits significant hepatic flap, multiple spider naevi on his torso, and mild abdominal distension with shifting dullness.
The patient is afebrile and denies any recent history of infection.
His blood sugar level is 6.8 mmol/L.
What is the next appropriate step in management?
MRCP2-1898
A 20-year-old woman with type 1 diabetes presents with chronic diarrhoea and weight loss. She reports passing large volumes of watery stools at least four times a day without mucous, blood or abdominal pain. Despite having a good appetite, she has become very slim. Her blood tests reveal a high HbA1c level and low potassium levels. All other tests, including B12, folate, calcium, erythrocyte sedimentation rate, C-reactive protein and thyroid function, are normal. What is the most likely cause of her diarrhoea?
MRCP2-1899
An 80-year-old male presents with lower abdominal pain, diarrhoea, and elevated serum lactate. Upon performing an abdominal CT scan, left-sided colitis from the distal transverse colon is observed, with the lower half of the rectum being spared. What is the most probable diagnosis?