Archives: MRCP Part 2

MRCP2-1857

A 35-year-old man with a history of ulcerative colitis is admitted to the hospital due to worsening symptoms over the past three weeks. He reports passing bloody stools six times a day. After being treated with intravenous steroids for three days, he complains of increasing abdominal pain. During examination, he has diffuse abdominal tenderness with rebound and a pulse of 122 bpm with a temperature of 39.2°C. Blood tests reveal several electrolyte abnormalities, including low potassium and albumin levels. An abdominal x-ray shows a loop of featureless transverse colon with a maximum diameter of 6.8 cm. The patient has been taking increasing doses of ibuprofen to control his pain and has recently undergone an endoscopic examination. According to the 2007 European Crohn’s and Colitis Organisation consensus guidelines on the management of ulcerative colitis, which electrolyte abnormality should be corrected first to prevent further colonic dilatation?

MRCP2-1858

A 35-year-old premenopausal woman visits her family doctor with a complaint of epigastric pain that has been bothering her for the past 2 weeks. The pain is sometimes felt behind her breastbone and is worse at night. She has tried taking antacids and omeprazole without any relief. Her weight is stable, and her bowel movements are regular. There is no history of stomach cancer in her family.
On examination, there are no significant findings except for her being overweight. Her complete blood count is within normal limits.
What is the next best course of action for managing this patient’s condition?

MRCP2-1859

A 50-year-old male presents with severe epigastric pain. The pain is constant, sharp in character and radiates to his back. He has a past medical history of 3 episodes of pancreatitis secondary to chronic alcoholism. On systematic enquiry he states that he has been suffering from diarrhoea over the past 6 months. The diarrhoea is foul smelling and difficult to flush. He also has excessive thirst and passes large quantities of urine each day.

Blood results are as follows:

Hb 102 g/l Na+ 136 mmol/l
Platelets 288 * 109/l K+ 3.8 mmol/l
WBC 18.2 * 109/l Urea 12.1 mmol/l
Neuts 14.8 * 109/l Creatinine 98 µmol/l
Lymphs 2.2 * 109/l CRP 66 mg/l
Random glucose 13.8 *mmol/l Amylase 120 U/l (normal < 140) What is the most likely diagnosis?

MRCP2-1860

A 75-year-old male presents with a 4-day history of vomiting and profuse watery diarrhoea, up to 7 times a day, with abdominal pain and a fever. He denies any haematemesis or melaena. He returned from a holiday to India 8 weeks ago and also visited his nephew in the Lake District, where he had a barbecue about 10 days prior. He has minimal medical history except a ‘cough and cold’ treated by his GP with 3 days of oral augmentin last week. His past medical history includes hypertension, gastric reflux and type 2 diabetes mellitus, for which he takes metformin, ramipril and lansoprazole. On examination, abdomen generally tender and distended, resonant to percussion. Bowel sounds are absent. Stool cultures were initially sent five days ago but the results are still awaited, the laboratory reports that the sample has been lost. A flexible sigmoidoscopy was performed, with the report stating yellow membranes in an inflamed sigmoid colon. What is the most likely diagnosis?

MRCP2-1861

A 38-year-old male presents to the acute medical unit with a history of 5 episodes of bloody stools per day for the past 4 weeks. He has a medical history of ulcerative proctitis but is not taking any regular medications. Despite initial treatment with rectal mesalazine, his symptoms have not improved. On examination, there is mild abdominal tenderness but no guarding, and the abdomen is soft. His vital signs are within normal limits, and his blood tests show a low hemoglobin level of 106 g/L. What is the most appropriate course of treatment at this point?

MRCP2-1862

A 28-year-old woman with a history of haemochromatosis presents to the antenatal clinic at 14 weeks gestation. She desires to continue with the pregnancy. On examination, her blood pressure is 110/75 mmHg, pulse rate is 70 beats per minute and regular. Cardiac function is normal, and a liver biopsy from 8 months ago shows no evidence of hepatic fibrosis.

Hemoglobin: 118 g/L
Platelets: 189 * 109/L
White blood cells: 7.5 * 109/L
Ferritin: 620 mcg/L

What is the most appropriate management strategy for haemochromatosis during pregnancy?

MRCP2-1863

A 37-year-old former intravenous drug user presents to the GUM clinic for follow-up. He reports a history of sharing needles in the past but has since stopped using intravenous drugs. He also admits to engaging in unprotected sexual activity with multiple partners, including one encounter three days ago. He decided to seek medical attention after learning about the risks of undiagnosed hepatitis C. He denies any previous episodes of jaundice and currently feels well.

The patient undergoes a battery of tests, which reveal the following results:

– Positive for hepatitis B core antibody (HBcAb)
– Positive for hepatitis C antibodies
– Negative for HIV antibody and p24 antigen

Further testing is conducted based on the initial results, which show:

– Negative for hepatitis B surface antigen (HbsAg)
– Positive for hepatitis B surface antibody (HbsAb)
– Negative for hepatitis B envelope antigen (HbeAg)
– Negative for hepatitis C RNA

What is the most accurate profile of this patient?

MRCP2-1864

A 32-year-old man with newly-diagnosed distal ulcerative colitis presents to the gastroenterology clinic for a follow-up appointment. He was last seen 3 weeks ago with complaints of abdominal pain and bloody diarrhoea, and reported opening his bowels about 6 times a day without fever or vomiting. He was started on rectal mesalazine.

During his current visit, he reports that his symptoms have not improved and he is still experiencing cramping abdominal pain with 6 bowel movements per day.

The patient’s vital signs are as follows:
Temperature 37.1ºC
Heart rate 90 bpm
Blood pressure 126/78 mmHg
Respiratory rate 16 breaths/min
Oxygen saturations 98% on air

On examination, his abdomen is soft but tender in the left iliac fossa. His cardiovascular examination is unremarkable.

What is the next best step in managing this patient?

MRCP2-1865

A 72-year-old patient presents to the emergency department with a four-day history of profuse diarrhoea. The patient has recently undergone treatment for cellulitis with clindamycin. There is no past medical history, and the patient is not taking any other medications.

Observations:

– Heart rate: 90 beats per minute
– Blood pressure: 118/78 mmHg
– Respiratory rate: 16/minute
– Oxygen saturations: 98% on room air
– Temperature: 38.2°C

Examination reveals mild abdominal tenderness with no peritonism.

Lab results:

– Hb: 140 g/L (Male: 135-180, Female: 115-160)
– Platelets: 195 * 109/L (150-400)
– WBC: 7.0 * 109/L (4.0-11.0)
– Na+: 139 mmol/L (135-145)
– K+: 4.1 mmol/L (3.5-5.0)
– Urea: 5.5 mmol/L (2.0-7.0)
– Creatinine: 90 µmol/L (55-120)
– CRP: 60 mg/L (<5) An abdominal x-ray is unremarkable. A stool sample is positive for Clostridium difficile toxin. The patient has completed full treatment courses of oral vancomycin followed by oral fidaxomicin but still has ongoing diarrhoea with type 7 stools eight days after the second course of antibiotic treatment and remains Clostridium difficile toxin positive. What is the appropriate management for this patient at this point?

MRCP2-1866

A 70-year-old man is admitted with diarrhoea having recently been an inpatient with pneumonia. He is having 6-8 episodes per day of watery, foul-smelling diarrhoea. Stool is sent for testing and Clostridium difficile toxin is detected.

He is treated with a 14-day course of oral vancomycin. At the end of this course, he describes no improvement and still has diarrhoea 6-8 times per day. Observations are as follows.

Respiratory rate 20 /min
Oxygen saturations 96% on air
Heart rate 88 beats /min
Blood pressure 135/70 mmHg
Temperature 38.2ºC

On examination, he appears dehydrated but the abdomen is soft and non-tender. An abdominal X-ray is requested and is unremarkable.

What is the best course of action?